The Golden Thread shows a cohesive narrative of a client’s experience based on therapist documentation. Progress notes are the third piece of clinical documentation in the Golden Thread, after the intake assessment and the treatment plan. They summarize what occurred in a specific therapy session, including clinical interventions. Progress notes are tied to SMART goals and objectives outlined in the treatment plan.
With the exception of an initial assessment (intake) document with a new client or when reopening a former client who was discharged, each therapy session is documented using a progress note.
A progress note includes:
Progress notes use the SOAP format, and a risk assessment and mental status notation further strengthen the documentation.
If you have a client contact between sessions that is not a billable service or a therapy session, you can document that using the phone/email consultation template.
As a resource for SonderMind providers, we’ve created a progress note template that you can access here.
To help you fill out progress notes, we’ve also developed examples featuring fictional clients. The information in each sample is for illustrative purposes only and does not contain real client information.
If you’re not a SonderMind provider, we invite you to join a community of mental health professionals who are dedicated to providing the highest-quality care and changing people’s lives. As part of the SonderMind community, you’ll have access to tools, resources, and support to provide the best care to your clients.
The Golden Thread: Using Medical Record Documentation Templates to Prove Medical Necessity
Initial assessment in the Golden Thread: Intake template
Road map for care in the Golden Thread: Treatment plan template
Documenting end of care in the Golden Thread: Discharge summary template
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