Individual Therapy Progress Note

Document an individual psychotherapy session, including interventions used, patient response, and progress toward treatment plan objectives for behavioral health and payer review.

Session Details

• Session date
  Date the individual therapy session occurred.
• Start time
  Time the session began.
• Session duration (minutes)
  Total face-to-face or telehealth session time in minutes.
• Service modality
  Select how the session was delivered.
• Provider name
  Clinician completing the note.
• Location
  Optional service location if needed for the record.

Clinical Context

• Primary diagnosis
  Diagnosis relevant to this session note. Use the minimum necessary detail required for clinical documentation.
• Targeted treatment plan objective
  State the specific treatment plan objective addressed in this session.
• Presenting concerns / current status
  Briefly describe the patient's current symptoms, concerns, or status at the start of the session.
• Symptom change since last visit
  Select the overall change observed or reported since the prior session.

Interventions and Patient Response

• Interventions used
  Select all interventions delivered during the session.
• Intervention details
  Describe the intervention content, techniques used, and any relevant clinical observations.
• Patient participation
  Select the level of participation during the session.
• Patient response
  Document the patient's response to interventions, including insight, affect, behavior, and any reported benefit.

Risk, Safety, and Progress

• Risk screening completed
  Indicate whether risk or safety screening was completed during this session.
• Current risk level
  Select the current risk level if assessed.
• Progress toward objective
  Select the overall progress toward the targeted treatment plan objective.
• Progress summary
  Summarize evidence of progress, barriers, and how the session supports the treatment plan.

Plan and Follow-Up

• Next steps
  Describe the plan for the next session, homework, referrals, or care coordination.
• Follow-up date
  Optional date for the next appointment or follow-up.
• Additional notes
  Use for any other clinically relevant information not captured elsewhere.