James Fitzgerald Therapy PLLC

Example of a Therapy Treatment Plan Progress Note

In an effort to be completely transparent and open with my clients, here is the outline of a standard progress note you would find in a client’s chart. A theme should naturally emerge, a “golden thread,” that should weave from the intake note and client history form, through the assessments, the integrative summary and treatment plan, through the progress notes, the outcome measures, the discharge summary, and the termination note.

Diagnosis

Based on screening, assessments, outcome measures, diagnostic tools, and interviews, with an integrative summary and SNAPV summary.

Mental Status, Attitude, and Appearance

A typical MSE paragraph begins with appearance and general behavior, noting such details as grooming, eye contact, psychomotor activity, and any obvious discomfort. The narrative then transitions to speech and language, commenting on rate, volume, fluency, and coherence, before describing mood as a subjective report and affect as the observed emotional tone and range. Thought process is documented next—linear, tangential, circumstantial, or disorganized—followed by thought content, where the clinician records the presence or absence of delusions, obsessions, preoccupations, or suicidal and homicidal ideation. Perceptual disturbances such as hallucinations are noted if present. The examiner then summarizes cognitive status: orientation to person, place, time, and situation; immediate, recent, and remote memory; attention and concentration; abstract reasoning; and estimated fund of knowledge. Finally, the paragraph closes with an appraisal of insight and judgment, along with a brief risk assessment if safety concerns arise.

Risk Assessment

A person-centered strengths-based assessment of risk (danger to self, others, or property). The risks associated with suicidality, homicidality, violent behavior, and threats to persons or property. The client will be informed of their rights and responsibilities as well as the clinician’s responsibilities and duty to warn as a mandated reporter, around the privacy and confidentiality limitations, rules, regulations, policies, and laws. Risk factors, level of risk, protective factors, safety plan, crisis plan, post-crisis plan, strengths and abilities, intent, means, plan, and lethality were discussed and documented. A follow up to the assessment is planned, including the discussion of an advanced directive for mental health care decisions.

Prescribed Medications, Compliance, Efficacy, Side Effects

Presenting Problem, Subjective Reports and Session Details

Session Data, Therapy Process, Interventions in Session

Treatment Plan, Long Term Goals, Objectives and Interventions

Assessment, Diagnosis, Risk Factors, Prognosis, Progress, Medical Necessity

Homework Assignments, Skills Practice, Follow Up, Next Steps