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Common Mistakes Found in Progress Notes

Some common mistakes made in writing progress notes.

  1. Not related to treatment plan.
  2. No clear intervention.
  3. No rehabilitation intervention.
  4. Does not indicate next steps or plan for next session and/or week.
  5. Too much or too little information.
  6. Only documents symptoms and/or functioning (monitoring).
  7. 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.
  8. Judgmental or subjective descriptions.
  9. No continuity from session to session or week to week. This would be a concern in team-based services like ACT and IRTS.
  10. Repetition from session to session or week to week without any evidence of attempts to change interventions or reframe goals and/or objectives.
  11. No evaluation if intervention is working or should be modified or changed.