Documenting therapy sessions in the Golden Thread: Progress note template

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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. 

When should I use progress notes?

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.

What information is in progress notes?

A progress note includes:

  • Details about the session (start/end times, CPT code)
  • Current diagnosis
  • Details about clinical interventions used in the session
  • Client progress in treatment tied to treatment plan goals

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.

How can I get the progress note template?

As a resource for SonderMind providers, we’ve created a progress note template that you can access here

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.
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You might also want to read

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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**Disclaimer: This document is intended for educational purposes only. Please check with your legal counsel or state licensing board for specific requirements.

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