Facebook tracking pixelMental Health Progress Note
Back to Templates
Behavioral Health Therapist
20-25 minutes

Mental Health Progress Note

The Mental Health Progress Note template by s10.ai is crafted for mental health professionals to meticulously document client sessions. Featuring sections for symptom description, objective content, supplementary notes, and treatment plans, this template enables counselors to detail symptoms, therapeutic interventions, and client progress, ensuring comprehensive session records. Perfect for monitoring mental health treatment plans and progress, this tool is indispensable for mental health practitioners utilizing s10.ai, the AI medical scribe. It enhances documentation efficiency, allowing counselors to dedicate more time to client care.

3,432 uses
4.6/5.0
D
Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

Symptom Overview and Subjective Account:
“The client reported experiencing the following symptoms”
[Include all symptoms discussed]
[Describe frequency of symptoms]
[Describe duration of symptoms when they occur]
[Describe severity of symptoms such as mild, moderate, and severe]
[Describe impact on the client's daily activities and functioning]
[Report on privacy for confidential conversation]
[Use "the client reported" when describing symptoms]
Objective Content:
[Describe at least 3 main themes the client discussed during the session]
[Specific details the client shared, such as quotes from the client]
[Describe at least 3 therapeutic interventions used during the session and the rationale for their use]
[Explanation of client's response to interventions]
[Use "the client reported" and "the therapist used" when describing interventions used and themes discussed by the client]
Additional Notes / Assessment:
[Additional comments about client’s progress]
[Location where session occurred such as at home, in the car, at the office]
[Assessments given and their scores]
Plan:
[Ongoing treatment plan and Homework assigned]
[Topic of discussion for next session and expectations for what will occur between sessions]
[Time and date of next session]
[Type of next session]
Sample Clinical Note

Example of completed documentation using this template

Symptom Description and Subjective Report:
"The client endorsed the following symptoms"
The client reported experiencing anxiety, difficulty sleeping, and feelings of sadness. These symptoms occur daily and last for several hours each time. The severity of symptoms is moderate, impacting the client's ability to concentrate at work and engage in social activities. The client reported that these symptoms have led to decreased productivity and withdrawal from social interactions.
Objective Content:
The client reported feeling overwhelmed by work responsibilities, experiencing tension in family relationships, and a lack of motivation. The client shared, "I feel like I'm constantly on edge and can't relax." The therapist used cognitive-behavioral therapy to address negative thought patterns, mindfulness exercises to reduce anxiety, and role-playing to improve communication skills. The client reported feeling more relaxed after the mindfulness exercises and expressed a willingness to try the role-playing techniques at home.
Additional Notes / Assessment:
The client has shown progress in managing anxiety through mindfulness practices. The session occurred at the therapist's office. The Beck Anxiety Inventory was administered, and the client scored a 22, indicating moderate anxiety.
Plan:
The ongoing plan for treatment includes continuing cognitive-behavioral therapy and practicing mindfulness exercises at home. The client was given homework to journal about daily stressors and practice deep breathing exercises. The topic of discussion for the next session will be stress management techniques, with an expectation to explore additional coping strategies. The next session is scheduled for 8 November 2024 at 10:00 AM, and it will be an individual therapy session.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template for Symptom Description and Subjective Report is designed to streamline the documentation process for healthcare professionals, ensuring accurate and detailed patient records. Clinicians can efficiently capture all symptoms reported by the client, including frequency, duration, and severity, as well as the impact on daily living activities. The template also facilitates the documentation of confidential conversations, maintaining privacy and trust. In the Objective Content section, practitioners can document key themes discussed, specific client quotes, and therapeutic interventions applied, along with the client's responses. Additional Notes allow for tracking client progress, session locations, and assessment scores. The Plan section provides a structured approach for ongoing treatment, including homework assignments, future discussion topics, and scheduling details for upcoming sessions. By adopting this template, clinicians can enhance their documentation accuracy, improve patient care, and optimize clinical workflows.
Frequently Asked Questions

Common questions about this template and its usage

Ready to transform your practice?

Join thousands of clinicians already using S10.AI to reduce administrative burden and improve patient care.