PROGRESS NOTES

Introduction:
It may be safe to say that clinical documentation is one of the least favorite tasks required of a
substance abuse counselor. Favorite or not, this era of accountability has made delivering
clear, comprehensive, and timely documentation of clinical services rendered more important.
 Legal Importance: Within the nightmare of a malpractice suit brought against a program
and/or practitioner a solid documented chart is universally recognized as one of the
critical elements of the best defense;
 Regulatory Importance: There are Federal, State, and contract Documentation
Standards which must be maintained or risks up to loss of program licensing and/or
certification could result;
 Audience Importance: Audiences for the record can include other members of the
treatment team: on-call and volunteer staff, auditors, and even the patient. Their needs
may vary but few needs are met by a poorly organized, incomplete, or difficult to
decipher clinical record. This is especially true regarding the clinical record’s
importance as a basis to direct “continuity of care” issues.
 Financial Importance: There’s a saying, “if it’s not documented, it didn’t happen.”
Payment from third party sources (insurance, Medi-Cal, contracts and grants) relies on
not only documenting that a billable service was provided, but with Medi-Cal, if some of
the regulatory standards for the documentation are not met, payment will be
disallowed.
 Clinical Importance: There’s no question that the therapeutic bond is important to the
success of treatment. Research has shown that having a consensus on goals (patient-
counselor) and agreement on the methods (means and tasks) to achieve the goal are
key elements in forming a positive therapeutic bond and engaging in treatment. If
clinical notes are used to document progress in treatment, they help to keep the
therapeutic process on task. This is the primary purpose of the progress note: to
improve and enhance the treatment process by helping the counselor track the
patient’s progress in treatment while staying focused on the plan.

So, documentation is important; case notes are important; and, regardless of the reason, most
counselors struggle or feel frustrated with writing clear and concise clinical case notes. When I
reflect on how much training is provided for building documentation skills, it is easy to see why
some agencies are in a documentation crisis—routinely losing time and revenue. It’s a reality,
clinical documentation skills do not come naturally; they are learned with training and by
practice, practice, practice. I hope some parts of this guide can help.
 I. COMMON ELEMENTS: There are some “subjective” preferences that counties or
reviewing entities may require in a progress note, but common standards include:
A. Include all of the elements required by Title 22—Names/signatures; dates; topic
of service
B. Document progress toward Treatment Plan Goals and/or emergence of
conditions that may require adjustments to the treatment plan—reference
ASAM Dimension
C. Summarize and be succinct—avoid overworked narrative, descriptive notes that
detail what was observed but provide little or no information on interventions or
actions taken.
D. Use a standard of documentation (see formats below)

II. FORMATS: There are number of acceptable formats for progress notes. Three
common formats are (see the table below and Appendix 1-3):

S.O.A.P B.I.R.P. D.A.P.

S (Subjective)- The data gathering B (Behavior)- Subjective data D (Data)- Subjective and
section that contains information from about the client [key Objective data about the
the patient; key words and brief statements] and Observations session; include type of
statements the patient says which made by the counselor [factual, session(s) attended.
summarize the theme of the session measureable, and observable
O (Objective)- Factual, measureable data)
and observable data
A (Assessment)- Summary of the I (Intervention)- Methods used A (Assessment)- Summary of
counselor’s clinical thinking regarding to address goals and objectives the counselor’s clinical
the data from the “S” and “O” portion including content and process thinking regarding the data
of the notes. Include goals, objectives, of session from the “S” and “O” portion
and interventions addressed in the R (Response)- Response to of the notes. Include goals,
session and patient’s intervention and progress objectives, and interventions
response/progress. toward goals and objectives addressed in the session and
patient’s response/progress.
P (Plan)- Plan for future work; reflect P (Plan)- Documenting what is P (Plan)- Plan for future work;
follow-up needed or completed planned for future work reflect follow-up needed or
completed
III. WRITING THE NOTE: Remember you have to attend to all of the details including the
date, name (signed and typed/printed), and topic of the session: then there is the
note. The Standard of Care includes the expectation that progress notes include
details that describe the patient’s response in the treatment session (intervention;
assignment; topic discussion; etc.) and requires a description of the patient’s
progress toward treatment goals and objectives. This section will include a closer
review of the S.O.A.P. and D.A.P. formats.

Documenting patient progress using the S.O.A.P. format. There are four components
to S.O.A.P. notes with the “Data” collection divided into two parts, Subjective and
Objective.

A. Subjective- The Subjective is a summary statement by the client (or family

member) disclosed to the counselor and/or group. The statement chosen should
capture the theme of the session, being as brief and concise as possible. This is
“subjective” because it is information from the patient’s perspective, frequently
quoting his/her own words. But is it best/required to use exact quotations of
what the patient said? Consider a statement made by John, a client in your early
recovery group:

 His exact quote: “I’m sick of this sitting in group and talk, talk, talk
about problems. That doesn’t do anything for anyone but stir up
shit. Fact is, it makes me want to use”

 Counselor’s paraphrase using only key words or a very brief

direct quote: John said he’s not sure A.A. is really helping him. He
claims, in fact, “it makes me want to use.”

 Counselor’s paraphrase communicating the client’s perspective

without a direct quote: John questioned the value of attending
A.A.
Which is best? It is that one which most accurately, clearly and concisely
reflects current areas of client concern (treatment plan issues or an
evolving problem area you may treatment plan about) and supports or
validates the counselor’s interpretations and interventions in the
assessment and plan sections of the SOAP note.
What if there is more than one theme the client brings into the session?
The quick answer is, you a concise, subjective statement about each
 noting it is helpful to identify the relevant ASAM dimension or problem
area following each statement. For example:
Counselor’s paraphrase using only key words or a very brief direct
quote: Client reported his cravings are “still strong” and he frequently
thinks about leaving treatment to go use (Dimension 5, relapse risk). He
did note he is more comfortable talking in group and sees that it helps to
get support (Dimension 4 & 5). Overall he says he’s “feeling more hopeful
about recovery and getting back with his wife.” (Dimension 4 & 6)

Hint: It is advised to limit your use of patient quotations. First, when they are overused
they make the record more difficult to review for client themes and to track their
response to interventions. Second, it may be an hour or more before the note is written
and memory studies show that exact retention can be poor. Better to paraphrase than
quote inaccurately. In the place of “patient says”, you can use phrases like patient
“reports”, “states”, “indicates”, etc.

Also, if the client refers to someone else, indicate that person by initials not by name.
This makes it clear that the client is the focus, not the person the client is talking about.
It also guards against any breeches in confidentiality.

B. Objective: Essentially this is objective data about what the counselor observes
during the session (client’s affect, mood, body language, and appearance) and
matches/parallels the theme(s) expressed in the Subjective section.

For example: Client was 10 minutes late to group making a disruptive

amount of noise entering and getting seated. He looked down, with
slouched shoulders as he talked about craving but his affect brightened
and he made improved eye contact with the group as he spoke about the
value of group support and feeling hopeful.

Hint: Use quantifiable terms (can be seen, heard, counted, or measured). This can
include the patient’s general appearance, affect, tone of voice, or behavior.
If you feel you are unsure and must use the word “appeared” or “seemed”, follow the
statement with the phrase “as evidenced by” and describe.

“John appeared to be depressed as evidenced by his

less than usual verbal exchange and flat affect.”

Avoid personal judgment and value-laden, opinionated phrases such as:

“manipulative”, “obnoxious”, “normal”, etc. Instead, record observed behaviors as
clearly as you can.
C. ASSESSMENT: This component essentially summarizes the counselor’s clinical
thinking regarding the patient’s current status and progress toward treatment
goals. It generally includes information about;
 Counselor’s impressions of patient’s current status and description of
progress in treatment: What is the patient’s current response to the
treatment plan? Does the plan need revision?

For example: “John’s participation remains poor and he did not present
sober support assignment (Dimension 5). Some progress indicated by his
disclosing ambivalence rather than total rejection of sober support
(Dimension 4 and 5).

Hint: Indicate the problem number including sub-goal for problems you are
referencing in the “Assessment” section. Including the ASAM dimension
number is also advised. For example, John’s social support problem was a
Dimension 5 issue.

Also reported in the Assessment portion would be:

 Results of any screenings, assessments, or testing: This could include UA
testing or any medical/psychological tests. If you are tracking self-help
meeting attendance, include that information here.

 What are any counselor hypothesis about additional problems,

diagnoses, or complicating factors: The assessment section can include
any clinical impressions for which insufficient information exists to make
a determination or the counselor needs to refer to another clinician to
make a clinical diagnosis. When writing a clinical impression, counselors
should identify them as such.
For example: John especially avoids talking about his service time
and left group once when a peer asked him if he saw combat. He
has complained of not sleeping well at times and feeling anxious.
Ruling out a traumatic stress condition seems advised.

 Data about the Counselor: This may include objective data about what
therapeutic responses, interventions, or techniques were employed with
the patient during the session. As a part of this, also include the patient’s
response to the intervention. For example:
 As John questioned the value of support from A.A. I intervened
with a motivational task, asking if he would be willing to list three
not-so-supportive things about A.A. Then, I asked him if he could
list three possibly supportive things about A.A. He took more time
to identify the supportive things but completed the task.

 Data about Therapeutic Tasks: If therapeutic tasks such as homework or

behavior plans (Action Steps) were a part of the session, include
comments about reviewing and processing those items. This also includes
detailing any activities that reflect a clear association to the goals and
objectives noted in the client’s treatment plan.

For example: John was scheduled to present his recovery

assignment on “identifying sober support resources in the
community.” He shared his thoughts on A.A. bud did not have the
assignment completed (Problem 1.3, dimension 5).

Outside reports can also be included, such as results from urinalysis or

breathalyzer tests.

Hint: There are times when a patient not only does not present their
“homework”, they don’t verbally participate. Even in those instances
there is frequently a theme in the session that relates to the patient’s
treatment plan. In those instances, rather than say, “the patient was
alert and attentive but did not participate”, it would be better to
document progress by documenting, “patient notably did not verbally
participate even though [the theme of the session] is a treatment issue
in his/her treatment plan.” The assessment portion of the note can
follow-up noting concern about his/her progress.

D. PLAN: The last component in the note is the plan. This describes what will
happen next.
 Plan for the next session: When; where (if there is a question);
What will the focus be; any assignments or special tasks?
 What is the plan for any special activities: This may include testing;
referrals; revision of treatment plan.

For example: “In addition to continuing group sessions as scheduled, plan

to meet with John to discuss a referral for a mental health assessment.
 John will continue to work on his sober support assignment and will
present it to group next week.”
EXAMPLES AND EXERCISE

Documenting Client Progress Using S. O. A. P. Method

Example of Acceptable S.O.A.P. Note

GRP GROUP SESSION_TOPIC: Recovery Skills
01/03/2013; 1330 hours; Duration: 40 minutes
S: Client stated that “I wanted to talk to my kid about how guilty I feel about my drinking, but
I don’t know what to say?” Group gave him some positive feedback and he practiced
a role play of talking to his teenaged daughter about his drinking.
O: Tearful at times; gazed down and moved anxiously but mood lifted with support from
the group
A: Client seems to have gained awareness in how drinking behavior has embarrassed and
hurt his teenage children and appears to assume responsibility for his past behaviors.
Client making progress on improving relationship with family (Goal 2, Objective 2) and
using the group (non-using coping skill) for strong emotions rather than drinking (Goal 1;
objective 3)
P: Client to complete Goal 2, Objective 2 by talking to his daughter about his drinking in next
family group session.

Counselor Jones, CAC

Example Less Acceptable S.O.A.P. Note

TYPE OF NOTE
GROUP SESSION_TOPIC: Recovery Skills
01/03/2013; 1330 hours; Duration: 40 minutes
S: Client attended group but did not verbally participate.
O: Client seemed alert and attentive
A: Client still getting comfortable with the group process and talking about personal issues
P: Continue treatment.

Counselor Jones, CAC

OR-
GROUP SESSION_TOPIC: Recovery Skills
01/03/2013; 1330 hours; Duration: 40 minutes
S: Client attended group and talked about a county worker who is “Messing up with my pay. I went to
get my G.A. check and all they did was make me wait and I never did get my check.”
O: Client angry and agitated
A: Client vented for some time and was finally able to calm himself down. He resisted taking any
feedback from the group, claiming they don’t understand his situation.
P: Continue to support client.

Counselor Jones, CAC

General Checklist
1. DOES THIS NOTE CONNECT TO THE CLIENT’S INDIVIDUALIZED TREATMENT PLAN by reflecting:
a. CLIENT’S PROGRESS and/or
b. (Change in/New Information Regarding) CLIENT’S STATUS which may affect treatment
2. Is this note dated, signed, and legible?
3. Is the theme or topic of the session included?
4. Is the client name and identifier included on each page?
5. Has referral information (if given) been documented?
6. Are any abbreviations used are standardized and consistent?
7. Would someone not familiar with this case be able to read this note and understand what has occurred in
treatment FOR THE CLIENT?
8. Are any non-routine calls, missed sessions, or professional consultations regarding this
case documented?

Case Note Scenario

You are a case manager in an adult outpatient drug and alcohol treatment program primarily
working with young adults between the ages of 18 and 25 who have some sort of involvement
with the adult criminal justice system. J. M. is your patient. She
attends both group and individual therapy sessions. For the past three weeks she has
missed two group sessions, one individual session and has been 15 minutes late to another
individual session. J.M. is on probation for possession of a controlled substance and grand
larceny. Some of the problems on her treatment plan include:
a) Difficulty maintaining abstinence during probation (legal) periods
b) Continuing pattern of harmful consequences from use of alcohol and other drugs
c) Uses alcohol and other drugs to manage strong emotions
She has been in treatment for approximately two months. You, as her case manager, have
asked her to attend this session after missing her last individual appointment.

Case Manager: “I am glad to see you made it today. I am worried about you, you have missed
several sessions in the past three weeks.”

J.M.: “I’ve just been really busy lately. You know, it is not easy doing all this stuff--staying clean,
working, and making all these appointments. Are you really worried about me, or are you just
trying to get info on me for my mom and probation officer?”

Case Manager: “You seem a little defensive and irritated. Are you upset with me, your
Mom, your probation officer, or with all of us?”

J.M.: “I don’t know...it just feels like everyone is on my case. I am tired of

having to report to everyone where I am going, what I am doing, why
I am doing things, and not doing others. I am just so tired of everyone
watching me. I guess that includes you too.”

Case Manager: “So I am included on this list of people who watch over you. How did I
get on this list?”
J.M.: “You told my probation officer that I had missed treatment sessions without talking to me
first!

Case Manager: “And that makes you feel...”

J.M.: “I’m pissed off. I thought you were different. I thought I could trust you, but
you are just like everyone else in my life.”

Case Manager: “Just like everyone else, meaning?”

J.M.: “You go over my head, treat me like a child, don’t talk with me first. I
hate when people do that. Why did you have to talk to my P.O.? Why couldn’t you just have
talked to me?

Case Manager: “It sounds like I hurt your feelings and broke some kind of trust with
you.”

J.M.: “Yeah, it feels like that.” (She stops talking and looks at the ground,
wiggling her leg back and forth.)

Case Manager: “Have you felt this way before; like the person you trusted let you down?”

J.M.: (slowly raises her head and nods.)

Case Manager: “When did you feel like this, Jennifer?”

J.M.: “When my dad divorced my mom, about two years ago. He promised he
would stay in contact with me. Oh, he did for a while, but then it was like I didn’t exist.
I didn’t hear from him until I got arrested. I hate talking about this stuff!”

Case Manager: “I know it is hard talking about this and it brings up a lot of strong
feelings for you, but we need to do this. How are the feelings you have regarding trust related
to your alcohol and drug use?”

J.M.: “I don’t want to talk about this!”

J.M. grabs her backpack and walks out of the counseling room. The Case Manager
attempts to get her to return, but she keeps walking.