A clinical document created by a mental health professional—such as a counselor, psychologist, psychiatrist, or social worker—that records the details of a client’s therapeutic session and tracks the client’s progress over time. It serves as a legal and professional record of care and is essential for continuity, communication, evaluation, and accountability in treatment.

Progress notes typically include relevant observations about the client’s current status, the interventions or techniques used during the session, the client’s response to those interventions, any significant changes in behavior or mood, and plans or recommendations for future sessions. These notes are kept in the client’s confidential medical record and must adhere to ethical, legal, and professional standards as outlined by licensing boards, health care institutions, and federal regulations like HIPAA (Health Insurance Portability and Accountability Act).

There are various structured formats for writing progress notes, with one of the most common being the SOAP format, which stands for Subjective, Objective, Assessment, and Plan. Another widely used structure is DAP (Data, Assessment, Plan). These formats help ensure that the information documented is clear, organized, and clinically relevant.