Progress Notes - Learn More
Common Mistakes Found in Progress Notes
Some common mistakes made in writing progress notes.
- Not related to treatment plan.
- No clear intervention.
- No rehabilitation intervention.
- Does not indicate next steps or plan for next session and/or week.
- Too much or too little information.
- Only documents symptoms and/or functioning (monitoring).
- Use of clinical language, jargon or terms that are not descriptive or unique to recipient, such as “psychiatrically stable”, “depressed”, “anxious” or “manic” among others.
- Judgmental or subjective descriptions.
- No continuity from session to session or week to week. This would be a concern in team-based services like ACT and IRTS.
- Repetition from session to session or week to week without any evidence of attempts to change interventions or reframe goals and/or objectives.
- No evaluation if intervention is working or should be modified or changed.