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Progress Notes Overview

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Progress notes evaluate a client's treatment goals and their use of treatment services, to help determine the current and future needs for a client's treatment.

Progress notes can be related to a treatment plan's objectives, and the actions taken to deal with a client's problems.

These notes are written by physicians, nurses, clinical staff. Progress note documentation is included in the client's chart, and is used for medical, legal, and billing purposes. A new progress note is required for each visit.

Progress notes:

  • Document client care and clinical events relating to a client's diagnosis and treatment.
  • Store medical facts, communicate a client’s condition to clinical users.
  • One progress note is written per appointment or service.
  • Information can be added to progress notes through the Append Progress Notes form.
  • Clinical staff review notes to determine a client's progress toward treatment and goals, and future needs.