Progress notes document a patient’s current condition, care, response to treatment, and changes over time. They help clinicians communicate with other providers, support continuity of care, and explain the reasoning behind treatment decisions.
- What changed since the previous encounter
- What the patient reported
- What the clinician observed or measured
- What treatment or intervention was provided
- How the patient responded
- What happens next
Progress does not always mean improvement. Notes may document improvement, stability, deterioration, new symptoms, treatment intolerance, or a change in the care plan.
What Is a Progress Note?
A progress note is a clinical record that documents a patient’s status, treatment, response, and updated plan during an ongoing episode of care. Notes may be written by physicians, nurses, therapists, behavioral health professionals, and other clinicians.
- Current symptoms or concerns
- Changes since the previous visit
- Examination or assessment findings
- Treatments and interventions
- Patient response
- Progress toward goals
- Updated clinical assessment
- Follow-up plan
A progress note describes the purpose of the document. SOAP, DAP, BIRP, PIE, and narrative notes are different formats clinicians can use to organize that information.
What Should a Progress Note Include?
Patient and encounter information
Include the date, time, provider, encounter type, and patient identifiers required by the organization.
Patient‑reported status
- Symptoms and pain
- Functional changes
- Medication response
- Treatment adherence
- New concerns
- Changes since the previous encounter
Include clinically relevant details rather than reproducing the entire conversation.
Objective findings
- Vital signs
- Range of motion
- Strength
- Gait
- Functional testing
- Mood and affect
- Wound appearance
- Laboratory or imaging results
Interventions provided
Document the care delivered during the encounter, including treatment, procedures, education, care coordination, or other interventions. Add parameters such as duration, dosage, assistance level, or exercise progression when they affect clinical interpretation.
Patient response
- Tolerated treatment
- Reported symptom improvement
- Required assistance or cueing
- Demonstrated improved performance
- Experienced an adverse response
- Could not complete the intervention
Clinical assessment
- Improvement or deterioration
- Remaining symptoms or impairments
- Progress toward goals
- Response to treatment
- Barriers to recovery
- Continued need for care
- Changes in the clinical impression
Plan
- Continuing or modifying treatment
- Progressing an intervention
- Monitoring a symptom
- Ordering testing
- Referring to another provider
- Reassessing an outcome measure
- Changing visit frequency
- Preparing for discharge
Avoid vague plans such as “continue current treatment” unless that treatment is clearly defined elsewhere.
Progress Note Example
The example below shows how raw encounter details can become a concise therapy progress note.
Raw encounter details
- Right knee pain decreased from 6/10 to 3/10.
- Patient still has difficulty descending stairs.
- Knee flexion increased from 105 to 115 degrees.
- Patient completed squats and step-down exercises.
- Verbal cueing was required to reduce medial knee collapse.
- Exercise intensity increased without additional pain.
- Continue treatment twice weekly and progress eccentric loading.
Completed progress note example
Subjective: Patient reports that right knee pain has decreased from 6/10 to 3/10 since the previous visit. The patient continues to experience difficulty descending stairs. Objective: Right knee flexion improved from 105 to 115 degrees. The patient completed squats and step-down exercises. Intermittent verbal cueing was required to reduce dynamic knee valgus during step-downs. Assessment: The patient demonstrates improved knee mobility, pain, and exercise tolerance. Deficits in eccentric quadriceps control continue to limit stair descent. Exercise intensity was progressed without increased symptoms. Plan: Continue treatment twice weekly. Progress eccentric quadriceps loading and reassess stair tolerance at the next visit.
This example identifies what changed, connects objective findings to the assessment, and provides a specific plan.
Progress Note Templates
Use these templates as starting points. Every note should be updated to reflect the current patient encounter.
General Progress Note Template
- Date and encounter type: [Date, time, location, and type of encounter]
- Patient-reported status: [Symptoms, concerns, function, and changes since the previous encounter]
- Objective findings: [Observations, measurements, examination findings, or results]
- Interventions: [Treatment, procedures, education, or care provided]
- Patient response: [Tolerance, participation, symptom response, or outcome]
- Assessment: [Interpretation of current status and progress]
- Plan: [Next steps, treatment changes, monitoring, or follow-up]
Medical Progress Note Template
- Reason for follow-up: [Current concern or condition being reviewed]
- Interval history: [Changes in symptoms, function, treatment adherence, or medication response]
- Objective findings: [Examination findings, vital signs, tests, or results]
- Assessment: [Updated diagnosis, clinical impression, or problem status]
- Plan: [Medication, testing, referrals, education, and follow-up]
Therapy Progress Note Template
- Patient report: [Symptoms, functional changes, adherence, and concerns]
- Objective measures: [Range of motion, strength, mobility, functional testing, or other measures]
- Interventions performed: [Therapeutic exercise, manual therapy, education, activities, or modalities]
- Response to treatment: [Tolerance, cueing, symptoms, and performance]
- Progress toward goals: [Improvement, stability, deterioration, or remaining barriers]
- Plan: [Progressions, modifications, home program, and reassessment]
Spend less time turning encounters into structured notes. OneChart captures patient conversations or clinician dictation and maps relevant details into predefined or custom templates.
Nursing Progress Note Template
- Patient condition: [Current clinical status and symptoms]
- Assessment findings: [Vital signs, observations, screening findings, and changes]
- Care provided: [Medication, wound care, positioning, education, or other intervention]
- Patient response: [Effect of care and current status]
- Communication: [Provider contacted, escalation, or new orders]
- Follow-up: [Monitoring, precautions, and next actions]
Behavioral Health Progress Note Template
- Presenting status: [Symptoms, functioning, and relevant developments]
- Intervention: [Therapeutic method, technique, or education provided]
- Client response: [Participation, engagement, insight, and response]
- Progress toward goals: [Change related to the treatment plan]
- Risk and safety: [Relevant safety findings or actions, when indicated]
- Plan: [Next session focus, assignments, referrals, or treatment changes]
Types of Progress Notes
Content and emphasis vary by specialty and setting.
Medical Progress Notes
- Interval history
- Examination findings
- Test results
- Medication response
- Updated assessment
- Follow-up decisions
Therapy Progress Notes
- Functional limitations
- Objective measurements
- Treatment provided
- Patient response
- Progress toward functional goals
- Need to continue or modify care
Nursing Progress Notes
Document the patient’s condition, nursing assessments, interventions, response to care, and communication with the healthcare team.
Behavioral Health Progress Notes
Document clinically relevant information about symptoms, functioning, interventions, treatment response, and progress toward care-plan goals without reproducing every sensitive detail discussed during a session.
Daily Progress Notes
- Changes since the previous day
- Current problems
- New findings
- Response to treatment
- Immediate clinical priorities
- Next steps
Daily notes should add meaningful information rather than copying the previous entry without updates.
Progress Note Formats
- SOAP: Subjective, Objective, Assessment, Plan — widely used in medical, therapy, and other clinical settings.
- DAP: Data, Assessment, Plan — combines subjective and objective information; common in behavioral health.
- BIRP: Behavior, Intervention, Response, Plan — emphasizes presentation, intervention, and response.
- PIE: Problem, Intervention, Evaluation — commonly associated with nursing documentation.
- Narrative: Chronological prose instead of fixed headings; still should make findings, interventions, responses, and next steps easy to identify.
How to Write a Progress Note
- Review the previous progress note: Check prior status, goals, and planned follow-up to establish a baseline for the new note.
- Document what changed: Identify changes in symptoms, function, measurements, treatment response, risk, diagnosis, or clinical impression.
- Separate patient reports from clinical findings: Distinguish what the patient reported from what the clinician observed or measured.
- Record relevant interventions: Document the care provided and any parameters needed to understand the treatment.
- Describe the patient’s response: State whether the patient improved, tolerated treatment, required assistance, experienced symptoms, or could not complete the intervention.
- Connect findings to clinical reasoning: Support conclusions with objective findings and explain their significance.
- Write a specific plan: Explain what will be continued, changed, progressed, monitored, referred, or reassessed.
- Review the note for accuracy: Check patient information, missing findings, unsupported conclusions, copied text, unclear abbreviations, incorrect measurements or medications, and completeness of the plan.
Progress Notes vs SOAP Notes
A progress note is the clinical document recording changing status, care, response, and plan. A SOAP note is one structure used to organize a progress note. Progress notes can use SOAP, DAP, BIRP, PIE, or narrative formatting.
Progress Notes vs Psychotherapy Notes
Behavioral health progress notes are part of the formal clinical record and document symptoms, functioning, interventions, response, and plan. Psychotherapy (process) notes may contain a therapist’s private analysis and are often kept separately; definitions and requirements vary by jurisdiction and organization.
Common Progress Note Mistakes
- Documenting activity without response (e.g., “exercises completed” with no outcome).
- Using vague language (e.g., “doing well” without details).
- Failing to document change or compare to prior status.
- Omitting objective evidence (measurements, findings).
- Mixing findings with interpretation instead of separating them.
- Copying outdated information or templates without review.
- Including unnecessary sensitive details not relevant to care.
- Writing a generic plan that lacks specifics.
- Completing notes too late, increasing missing or reconstructed details.
- Failing to review AI-generated notes for errors or omissions.
How AI Generates Progress Notes
- Clinician selects a progress note template.
- System captures the encounter or dictation.
- Speech is transcribed.
- Relevant clinical details are identified.
- Information is mapped into structured sections.
- A draft progress note is generated.
- The clinician reviews and edits the draft.
- The approved note is transferred into the patient record.
AI-generated notes still require clinician review. Potential errors include incorrect speaker attribution, misstated measurements, wrong medication or diagnosis names, missing negative findings, unsupported clinical conclusions, excessive detail, and information placed in the wrong section.
OneChart and similar tools can generate structured draft documentation and support integrations with EMRs, but the treating clinician remains responsible for the accuracy and completeness of the final record.
Progress Note FAQs
- How long should a progress note be? — Long enough to explain current status, care provided, response, assessment, and plan. Length varies by specialty, complexity, and setting.
- How soon should a progress note be completed? — As soon as practical after the encounter, following regulatory, organizational, payer, and legal requirements.
- Is a SOAP note a progress note? — A SOAP note can be a progress note; SOAP is a format, progress note describes the document’s clinical purpose.
- What is the difference between a progress note and a treatment note? — A treatment note may focus on services provided during a session; a progress note more explicitly documents changing status, response, and progress toward the care plan.
- Does a progress note always show improvement? — No. Notes can document improvement, stability, deterioration, a plateau, new symptoms, or treatment changes.
- Can AI write progress notes? — AI can generate draft notes from conversations or dictation, but a qualified clinician must verify and approve the final note.
- Who is responsible for an AI-generated progress note? — The treating clinician is responsible for ensuring the final progress note is accurate, appropriate, and complete.
Accurate, concise, and timely progress notes support patient safety, continuity of care, and appropriate clinical decision-making. Always review and finalize documentation carefully.