Therapy Progress Notes Cheat Sheet PDF: Clinical Words

If you searched for a therapy progress notes cheat sheet PDF, this page is built to be one. Print it, or choose Save as PDF in your print window, and keep it beside you while you write. It follows the order you write a note in: session details, presentation, mood and affect, behavior, interventions, client response, risk wording and the plan, with short lists of clinical words under each.

It also covers what most cheat sheets leave out: words to drop, how to say enough without saying too much, notes for no-shows and phone calls, late entries and corrections, and one short note built only from these lists.

Every client in this article is invented. Any resemblance to a real person is a coincidence.

How to print this page or save it as a PDF

On a computer:press Ctrl+P (Windows) or Cmd+P (Mac).
On a phone:open the browser's share menu and choose Print.
To keep a PDF:in the print window, choose "Save as PDF" as the printer.
To print only what you use:enter a page range, for example just the pages with the presentation and risk lists.

Keep the printout next to you when you write the note, not open during the session. The words help you describe what happened; they shouldn't decide what you look for.

The one-page version

If you print one thing, print this. Each line is a prompt; the brackets show the kind of words that belong there, and the lists further down fill them in.

Progress note cheat sheetTemplate · 28 parts to fill in

PROGRESS NOTE CHEAT SHEET

SESSION DETAILSDate, start and end time, session numberService and who attendedFormat: in person / video / audio onlyTelehealth: client's city and state, private spaceTreatment plan goal(s) addressed

PRESENTATIONAppearance: [groomed, disheveled, tired]Behavior: [calm, restless, slowed, guarded]Speech: [rate, volume, tone]Mood, client's words: "[quote]"Affect, what you saw: [range, quality, fit]Thought process: [linear, tangential, racing]Cognition: [alert, oriented, attention]Functioning: [sleep, work, relationships]Measures: [scale, score, date, last score]

RISKAsked about: [suicide, self-harm, harm to others]Client reported: [none / what was reported]If reported: [plan, intent, means, history]Protective factors: [people, reasons, supports]Judgment: [level] because [reasons]Action: [safety plan, means, 988, consult]

INTERVENTION[Verb] + [technique] + to address [goal]

RESPONSEEngagement: [engaged, hesitant, declined]Change: [rating before and after, skill shown]Homework: [done / partly done / not done]Goal: [met / progressing / no change / revised]Clinical reading: [one or two sentences]

PLANClient: [task, number, time frame]Therapist: [next focus, referral, coordination]Next session: [date, frequency, format]If-then: [what would change the plan]

Signature, credentials, date signed

Where each list goes in SOAP, DAP, BIRP and GIRP

The words stay the same whatever the format. Only the heading they sit under changes.

Session details:the header of every note.
Presentation, mood and affect:BIRP Behavior; DAP Data; SOAP Objective for what you saw and Subjective for the client's own words; GIRP Response, or Goal when the client reports on the goal.
Functioning between sessions:BIRP Behavior; DAP Data; SOAP Subjective; GIRP Goal.
Interventions:BIRP and GIRP Intervention; DAP Data; SOAP Objective or Plan, depending on your template.
Client response:BIRP and GIRP Response; DAP Data; SOAP Objective.
Clinical reading and progress:DAP and SOAP Assessment; the last line of Response in BIRP and GIRP.
Risk:with the presentation, and again in Assessment and Plan when it changes what you do.
Plan:the P in all four formats.

For complete notes in each format, see the BIRP note examples, the SOAP note examples for therapy and the DAP note examples.

Session details: the lines every note needs

Date of service, start and end time (or duration), session number
Service (individual, couples, family or group) and who attended
Format: in person, video or audio only
For telehealth: where the client was (city and state) and that they were in a private space
The treatment plan goal or goals the session addressed
Your signature, credentials and the date you signed

Sentences you can reuse:

"Session held by video. Client at home in [state], alone in a private room."
"Audio-only session at the client's request; video was not possible because [reason]."
"Client's partner joined for the last 15 minutes at the client's request."
"Session ended 10 minutes early at the client's request because [reason]."

Presentation words

Write what a colleague would have seen if they had been in the room. Pick the words that fit, then add one concrete detail.

Appearance

Well groomed, neatly dressed, casually dressed, dressed for the weather
Disheveled, unkempt, stained clothing, hair uncombed
Appeared tired, appeared older or younger than stated age
Change from usual: "unshaven and in the same clothes as last session"

Behavior and movement

Calm, relaxed, cooperative, attentive
Restless, fidgeting, pacing, wringing hands, tapping foot
Slowed movements (psychomotor slowing) or agitation (psychomotor agitation)
Guarded, withdrawn, startled easily, scanned the room
Arrived early, on time or [number] minutes late; on camera or camera off

Eye contact and engagement

Steady, intermittent, limited; looked away when discussing [topic]
Eye contact norms differ across cultures and for many autistic clients. Describe what you saw and leave the meaning out, unless it changed from what is usual for this client.

Speech

Rate: normal, rapid, pressured, slow
Volume: normal, soft, loud
Tone and rhythm: monotone, tremulous, hesitant, fluent
Amount: spontaneous, talkative, brief answers, long pauses before answering
Example: "Speech soft and slow, with long pauses before answering."

Thought process (how the client thinks)

Linear, logical, goal-directed, organized
Circumstantial (reaches the point after detours)
Tangential (drifts away and doesn't return)
Racing thoughts (client's report), flight of ideas, loose associations, thought blocking
Perseverative (keeps returning to the same point)

Thought content (what the client thinks about)

Preoccupied with, ruminating about, worried about [topic]
Intrusive thoughts or obsessions, in the client's description
Hopelessness, guilt or worthlessness, with a quote
No delusional beliefs expressed, or "expressed the belief that [belief]"
Thoughts of suicide or harming others: see the risk section

Perception

No hallucinations reported or observed
Reported hearing [description] when [context]
Appeared to respond to internal stimuli: "paused mid-sentence and looked toward an empty corner"

Cognition and orientation

Alert, drowsy
Oriented to person, place, time and situation
Attention: focused, easily distracted, needed questions repeated
Memory: recalled last session's plan without prompting, or forgot [what]

Insight and judgment

Always add the evidence, because "fair" means nothing on its own.

"Insight fair: links poor sleep to late-night drinking but doesn't see the drinking as a problem."
"Judgment good: called a friend for a ride instead of driving after drinking."

Mood and affect words

Mood is what the client tells you. Affect is what you see. Quote the mood and describe the affect. When the two don't match, say so: the mismatch is often the most useful line in the note.

Mood, in the client's words

"Mood: 'stressed but hanging in there.'"
"Rated mood 4/10 (6/10 last week)."
Words for a summary: euthymic (even, neither low nor elevated), depressed, anxious, irritable, angry, hopeless, numb, elevated

Affect, what you observed

Range: full, restricted (constricted), blunted, flat
Quality: euthymic, dysphoric, anxious, irritable, tearful, angry, fearful, elevated, expansive
Stability: stable, labile (shifts quickly)
Fit: congruent with mood and content, or incongruent ("laughed while describing being fired")
Change during the session: "affect brightened when talking about her son"

Example: "Mood 'okay, I guess.' Affect restricted and tearful, incongruent with her report; brightened briefly when discussing her garden."

Behavior and functioning between sessions

This is where a note shows why care is needed. Payers reviewing medical necessity often look for how symptoms affect daily life, and a number or an example shows that better than an adjective.

What to cover

Sleep, appetite, energy
Work or school: attendance, performance
Relationships and social contact
Self-care and daily routine
Substance use: what, how much, how often, and the change since last time
Avoidance: places, people or tasks the client now skips

Sentences you can reuse

"Reports sleeping 4 to 5 hours a night and waking around 3 a.m. most nights."
"Missed two days of work this month because of panic symptoms."
"Has turned down three invitations from friends since the last session."
"Reports drinking 3 or 4 beers on four nights this week, up from two nights."
"Is cooking dinner most nights again, which she had stopped doing in March."
"Symptoms continue to interfere with [area], for example [example]."

Measures

Name the measure, score, date and last score: "PHQ-9 total 11 on 10/20 (16 at intake on 8/25)."
Add the item that matters: "GAD-7 item 7 (feeling afraid, as if something awful might happen) scored 3."
For any item about self-harm, write what you did with the answer (see the risk section).

Intervention words: what you did

Use a verb, the technique and its target. "Used a thought record to examine the belief 'I always ruin things' (goal 2)" says what you did and why. "Used CBT" doesn't.

Verbs, grouped by what you were doing

Assessing:assessed, screened, administered, reviewed scores with, explored history of, clarified
Building the relationship:validated, normalized, reflected, summarized, attended to a rupture in the session
Teaching:provided psychoeducation on, explained, modeled, demonstrated, rehearsed, coached
Working with thoughts:identified, examined the evidence for, challenged, reframed, labeled thinking patterns
Working with behavior:scheduled, planned, practiced, problem-solved, set a graded step, assigned
Working with emotions:processed, explored, named, used grounding, helped the client tolerate
Building motivation:explored ambivalence, elicited change talk, weighed pros and cons, linked the task to the client's values
Reviewing progress:reviewed progress toward goal [#], updated the treatment plan with the client, revised an objective
Coordinating care:consulted with, coordinated with (with written consent), referred to, gave resources for
Safety:screened for risk, developed or reviewed a safety plan, discussed reducing access to lethal means

Technique names by approach

CBT:cognitive restructuring, thought record, behavioral experiment, activity scheduling, graded exposure, problem-solving training
DBT skills:diary card review, chain analysis, TIPP, opposite action, DEAR MAN, radical acceptance
ACT:defusion, values clarification, committed action, willingness, present-moment exercise
Motivational interviewing:open questions, affirmations, reflections and summaries (OARS), decisional balance, readiness ruler
Solution-focused:scaling question, exception finding, miracle question, coping question
Person-centered:reflective listening, empathic understanding, following the client's lead
Psychodynamic:explored recurring relational patterns, linked current feelings to earlier experiences, explored defenses and transference
Trauma-focused:psychoeducation on trauma responses, grounding, window of tolerance, cognitive processing, trauma narrative within a specific protocol
Family and couples:genogram, circular questions, tracked the interaction cycle, enactment, reframed the problem as shared
Children:child-led play, tracking, reflecting feelings in play, limit-setting, parent coaching
Groups:facilitated discussion of [topic], linked members' experiences, taught [skill] to the group, redirected off-topic discussion

Name only techniques you are trained in and actually used in that session.

Client response words: what changed

Engagement

Actively engaged, receptive, open, offered own examples, asked questions
Hesitant at first, then [what changed]
Guarded, gave brief answers, changed the subject when [topic] came up
Declined [activity] and said, "[reason]"
Tearful when [topic], laughed when [topic], went quiet when [topic]

Understanding and skill use

Explained [skill] back in own words
Practiced [skill] in session, with or without prompting
Identified [number] examples of [pattern] from the past week
Named a link between [trigger] and [reaction]
"Verbalized understanding" is common but thin. When you can, write what the client said.

Change in the session

"Distress 7/10 before the exercise, 4/10 after."
"Belief in the thought fell from 80% to 50%."
"Breathing slowed and shoulders dropped during the grounding exercise."

Homework

Completed, partially completed (two of five entries), not completed
Not completed because "[client's reason]"

Progress toward goals

Met:"Goal 3 met: has driven to work alone five days in a row."
Progressing:"Goal 1: two panic attacks this week, down from six at intake."
No change:"No change toward goal 2 this month; plan revised below."
Setback:"Symptoms increased after [event]; goal 1 continues with smaller steps."

Clinical reading (Assessment, or the end of Response)

"Suggests [what], because [evidence]."
"Symptoms appear to be maintained by [pattern], for example [example]."
"Client's response indicates [the step size is right / the approach needs to change]."
"Ongoing [symptoms] and their effect on [area] support continued weekly sessions."
Keep it to one or two sentences, and use the same diagnostic terms as the treatment plan.

Risk wording: suicide, self-harm and harm to others

These lines word what you assessed and did. They are not a way to assess risk. Use the screening tools, training and consultation your setting requires; many clinicians use a structured screen such as the Columbia Suicide Severity Rating Scale (C-SSRS) and build plans with the Stanley-Brown Safety Planning Intervention.

The rule that matters most: write what you asked and what the client said, then what you concluded and why.

When the screen is negative

"Asked directly about thoughts of suicide, self-harm and harming others since the last session. Client reported none."
"Client denied suicidal ideation, intent or plan, and denied thoughts of harming others."
"Denied" is standard in risk documentation. If it reads to you as doubt, "reported no..." says the same thing.
"SI/HI denied" on its own doesn't show what you asked. A full sentence takes ten more seconds.

When the client reports thoughts

"Client reported passive thoughts of death ('[quote]'), most recently [day], without intent or plan."
"Client reported thoughts of suicide [how often], most recently [when]. Asked about plan, intent, preparation, access to means and past attempts: [the client's answer to each]."
"Risk factors present: [for example, recent loss, living alone, increased drinking]."
"Protective factors: [for example, children at home, daily contact with a sister, engaged in treatment]."
"Clinical judgment: [low / moderate / high] acute risk, because [reasons]." The reasons matter more than the level.

What you did about it

"Reviewed the safety plan with the client and updated [section]; client keeps a copy [where]."
"Discussed reducing access to lethal means; client agreed to [specific step] by [when]."
"Gave 988 Suicide & Crisis Lifeline information (call or text 988, or chat at 988lifeline.org)."
"Consulted with [role] on [date]; agreed to [plan]."
"With the client's consent, called [support person] to [purpose]."
"Moved the next contact forward to [date]; sessions increased to twice weekly."
"Arranged [an emergency evaluation / a crisis team visit]; outcome: [what happened]."

Self-harm without suicidal intent

"Client reported [self-harm behavior, described in general terms] on [date], to [the purpose the client described]; denied suicidal intent."
"Asked whether any medical care was needed; client said [answer]."
"Explored what came before the urge; practiced [alternative skill]."

Harm to others

"Client expressed anger at [role] ('[quote]'); denied intent or plan to harm them; reported no access to weapons."
Duty-to-protect and duty-to-warn laws differ by state. Record what you assessed, who you consulted and what you did.

Abuse and neglect reports

"Mandated report made to [agency] on [date] at [time]; reference number [number]. Client [was / was not] told beforehand because [reason]."

Words to avoid in risk notes

"Contracted for safety" or "no-harm contract":a promise is not a plan. Describe the safety plan you made together instead.
"Client is not suicidal":a conclusion with no evidence. Say what you asked and what the client said.
A risk level with no reasons.

Plan words: what happens next

Client tasks with a number and a time frame:"Will practice the five-minute grounding exercise once a day and mark each day on the card." "Will draft the email to her landlord before Thursday."
Your next step:"Will introduce exposure step two next session." "Will repeat the GAD-7 at the next session."
Next session:"Next session 10/30 at 4 p.m. by video; weekly."
Referrals, with the client's decision:"Referred to a psychiatrist for a medication evaluation; client will call this week." "Offered a referral to a sleep clinic; client declined for now."
Coordination:"Under the signed release on file, will update the client's primary care provider on sleep and appetite."
Treatment plan:"Goal 1 continues." "Objective 2.1 revised to two social contacts a week." "Treatment plan review due 11/15."
If-then lines:"If panic attacks rise above three a week, will add a second weekly session."
Spacing and ending:"Agreed to move to every other week from 11/6." "Discussed ending treatment after three more sessions; client agreed."

Notes for contacts that are not sessions

Not every entry is a session note. A short, dated entry for each of these keeps the record complete.

No-show:"Client did not attend the 10:00 session. Called at 10:15 and left a voicemail. Next scheduled session: [date]."
Late cancellation:"Client canceled at 8:40 for a 10:00 session because [reason, if given]; rescheduled to [date]."
Phone check-in:"Phone call, 12 minutes, started by the client. Discussed [topic]. Risk: [what you asked and the answer]. Plan: [next step]."
Collateral contact:"Spoke with the client's mother for 15 minutes under the release signed [date]. Shared [what]. Learned [what]."
Coordination of care:"Sent a treatment summary to [role] on [date] under the release signed [date]."
Message from the client:"Client messaged at [time] asking [what]. Replied at [time]: [summary]."
Records request:"Client asked for a copy of their records on [date]; sent [what] on [date]."

Swap this for that

Most weak notes fail the same way: a conclusion where a description should be.

Instead of "client was noncompliant with homework," write "client did not complete the sleep log and said the week 'got away from me.'"
Instead of "client claims her manager singles her out," write "client reports her manager criticized her in two meetings this week."
Instead of "client admitted to drinking," write "client reported drinking five beers on Saturday."
Instead of "client was inappropriate," write "client raised his voice and swore at the front desk staff at check-in."
Instead of "session went well," write "client practiced the breathing exercise twice and rated distress 6/10, down from 8/10."
Instead of "client is doing better," write "PHQ-9 9, down from 15 at intake; back at work full time."
Instead of "discussed issues," write "explored conflict with her partner about money."
Instead of "client was in denial," write "client said, 'I don't have a drinking problem; everyone drinks like this.'"
Instead of "client was attention-seeking," write "client sent four messages between sessions asking to talk; reviewed the contact policy with her."
Instead of "client is unmotivated," write "client has not started the job applications in three weeks and said, 'What's the point?'"
Instead of "client was stable," write "no new symptoms reported; PHQ-9 unchanged at 7; sleeping about 7 hours a night."
Instead of "processed feelings," write "explored her anger at her brother for missing their father's funeral."
Instead of "client is borderline," write "client has a diagnosis of borderline personality disorder," and only when it matters to the session.

Words to drop or use with care

Noncompliant, refused:"did not," "declined" and "chose not to" say the same thing without blame.
Claims, alleges, admits:these suggest you doubt the client. "Reports" or "said" is neutral.
Manipulative, attention-seeking, resistant, unmotivated, in denial:labels. Describe the behavior instead.
Appropriate, normal, within normal limits (WNL), unremarkable:say what you saw. Appropriate to what?
Stable, improved, worse:compared with what? Add the number or the example.
Seems, appears:right for something you inferred, wrong for something you saw. If tears were running down her face, she "was tearful," not "appeared tearful."
Diagnoses as identities:"a schizophrenic," "a borderline." Write "a client with" or "diagnosed with."
Your own reactions:"I felt frustrated with him." Your reactions can matter clinically, but they belong in supervision, consultation or separately kept psychotherapy notes, not the progress note.
Other people's private details:names and personal information about partners, family or coworkers beyond what care needs. Refer to them by role.
Slang, nicknames and private shorthand:someone else may read the record, including the client.

Say enough, and no more

One of the pages ranking beside the cheat sheets is a forum thread asking for examples of "super vague" progress notes. The worry behind it is real: clients can usually read their record, and payers, courts and other providers may see it. The answer isn't vague notes. It's notes that keep the clinical facts and leave out the story.

The NASW Code of Ethics puts both halves in one standard: records should hold "sufficient and timely documentation" to deliver services and keep them continuous, and documentation should "protect clients' privacy to the extent that is possible and appropriate" and "include only information that is directly relevant to the delivery of services" (NASW Code of Ethics, 3.04).

Record the theme, not the transcript:"explored guilt about a decision she made during her divorce," not the decision and everyone involved.
Refer to other people by role:"her sister," "a coworker," not names.
Keep sensitive specifics to what care needs:sexual history, immigration status, legal trouble or another person's health belong in the note only when they shape the treatment.
Keep the clinical facts specific:symptoms, functioning, risk, what you did, how the client responded and the plan.
Keep private impressions elsewhere, if anywhere:HIPAA lets you keep psychotherapy notes, separate from the record, that document or analyze a session (45 CFR 164.501). They don't replace the progress note. Medicare's reviewers are not allowed to ask for psychotherapy notes, but a claim is denied when the rest of the record doesn't show the service was medically necessary (CMS Program Integrity Manual, chapter 3, section 3.3.2.6).

Too vague: "Client discussed stressors. Processed feelings. Will continue."

Enough: "Client reported conflict with her sister about their mother's care, with sleep down to five hours a night. Explored guilt and anger; rehearsed a boundary-setting script. Anxiety 7/10 before, 5/10 after. Will use the script in one call this week. Next session in one week by video."

Common abbreviations, and when to spell them out

Abbreviations save seconds and cost clarity. Use only the ones your practice has written down, and spell out anything a client, another provider or a reviewer could misread.

CL, Pt:client, patient (pick one and use it throughout)
Tx, Dx, Hx, Sx:treatment, diagnosis, history, symptoms
SI, HI:suicidal ideation, homicidal ideation
NSSI:non-suicidal self-injury
AH, VH:auditory or visual hallucinations
MSE:mental status exam
A&O x4:alert and oriented to person, place, time and situation
HW:homework
TP:treatment plan
ROI:release of information
PCP:primary care provider
SUDS:subjective units of distress (0 to 10 or 0 to 100)
f/u:follow-up
WNL:within normal limits (better: describe what you saw)
d/c:can mean discharge or discontinue, so always spell it out

Late entries, corrections and addenda

Never delete or write over a signed note. Add to it, with the date and your name. Medicare's review manual says the date and author of any amendment, correction or delayed entry "should be identifiable, and the change/addenda should be clearly and permanently denoted" (CMS Program Integrity Manual, chapter 3, section 3.3.2.5). The ACA Code of Ethics asks counselors who amend records to "properly note the amendments" (ACA Code of Ethics, A.1.b).

Late entry:"Late entry for the 10/20 session, written 10/23 at 9:00."
Addendum:"Addendum 10/24: client called after the session to add that [what]; risk screen [result]."
Correction:"Correction 10/24: the 10/20 note lists the session as video; it was in person."

One short note built from these lists

Here is a DAP note written only with lines from this page.

Invented client: a 67-year-old retired electrician we'll call Walt, eight months after his wife's death, in his fifth session.

Date of service: 10/21, 2:00 to 2:52, session 5
Individual psychotherapy, in person, in the office
Treatment plan goal 1: return to two weekly activities outside the home

Data: Client arrived on time, groomed but unshaven, in the same jacket as last session. Mood: "Gray. Weekends are the worst." Affect sad and restricted, tearful when describing Sunday dinners; brightened briefly when talking about his granddaughter. Speech slow and soft; thought process linear. Reports sleeping about five hours a night, skipping lunch most days and missing the last two Thursday woodworking group meetings. PHQ-9 total 16 (13 three weeks ago); item 9 scored 1. Asked directly about thoughts of suicide, self-harm and harming others: client reported passive thoughts ("Some nights I don't care if I wake up"), most recently Saturday, without intent or plan. Denied past attempts and thoughts of harming others. Reported no firearms at home; he gave his rifles to his son in March. Reviewed the safety plan from session 3 with him and added his daughter's number and two weekend activities. Used activity scheduling to plan Thursday's group and two morning calls with his daughter; client agreed to both and said, "Thursday I can do." Gave 988 information (call or text 988).

Assessment: Depressive symptoms have risen over three weeks, mostly on weekends, as he has pulled back from his main routine outside the home. Passive thoughts of death without intent or plan. Protective factors: close contact with his daughter, no access to firearms, engagement in treatment. Acute risk judged low for these reasons; chronic risk factors noted (recent bereavement, older age, living alone). Progress toward goal 1 has stalled.

Plan: Client will attend Thursday's woodworking group and call his daughter on Saturday and Sunday mornings. Therapist will repeat the PHQ-9 and risk screen next session and, under the release signed at intake, update his primary care provider on sleep and appetite. Next session 10/28 at 2:00, in the office. If passive thoughts become more frequent, move to twice-weekly sessions; if intent or a plan emerges, reassess right away and follow the safety plan's emergency steps. Goal 1 continues.

Where each line came from:

Session details:the three lines above the note.
Presentation:groomed but unshaven, slow and soft speech, linear thought process.
Mood and affect:the quote, then "sad and restricted," "tearful" and "brightened."
Functioning:sleep, skipped lunches, the missed group meetings.
Measures:the PHQ-9 with the earlier score and the item that matters.
Risk:what was asked, what Walt said, access to means, protective factors, and a judgment with reasons.
Interventions and response:the safety plan review, activity scheduling, and his own words.
Plan:tasks with days, the next screen, coordination under a release, and an if-then line.

How this works in TranqBay

TranqBay is practice software for therapists in private practice: booking, video sessions, session notes and a practice website in one place. Here is where a cheat sheet like this fits.

Pick a format for each session note: BIRP, DAP, SOAP or GIRP, or a blank note in your own structure.
A short prompt under each heading: SOAP's Objective, for example, prompts for what you observed (appearance, mood, affect and speech), which is where the presentation and affect lists above go.
The session's details sit beside the note: the date, time, duration, modality and the client's presenting concerns stay in view while you write, so the session details lines are already in front of you.
Structured formats such as SOAP, DAP, BIRP and GIRP are part of the advanced note templates, which some plans include.

To see how a session note sits next to the booking and the video session, look at the sessions section on practice.tranqbay.health.

Frequently asked questions

Is there a PDF of this progress notes cheat sheet?

The page is the cheat sheet. Press Ctrl+P or Cmd+P and choose Save as PDF to keep a copy, or print only the pages with the lists you use. The one-page version near the top is the part most people keep on their desk.

What clinical words should I use in progress notes?

Words that describe what you saw and did: observable behavior (restless, tearful, slowed speech), the client's own words in quotes, named techniques (cognitive restructuring, chain analysis) and measured change (distress 7/10 before, 4/10 after). Leave out labels that judge, such as "manipulative" or "noncompliant."

What is the difference between mood and affect in a progress note?

Mood is how the client says they feel, so quote it. Affect is what you observe: its range (full, restricted, flat), its quality (anxious, tearful, irritable), its stability and whether it fits what the client is saying.

What should you not write in a progress note?

Labels without evidence, your personal reactions, other people's private details beyond what care needs, slang and shorthand only you understand. A good test: would the note still be accurate and fair if the client read it?

How do I document that a client denied suicidal thoughts?

Write what you asked and what the client said: "Asked directly about thoughts of suicide, self-harm and harming others since the last session. Client reported none." If you used a measure item, such as PHQ-9 item 9, add its score.

How long should a therapy progress note be?

For a routine outpatient session, a few sentences per section is usually enough. Intake, crisis and complex sessions need more. Aim for a note a reviewer can read in a minute that still shows what you did, how the client responded and why care continues.

Are progress notes the same as psychotherapy notes?

No. HIPAA defines psychotherapy notes as notes kept separate from the rest of the record, and leaves out of that definition session start and stop times, modalities, test results, symptoms, the treatment plan and progress (45 CFR 164.501). Progress notes are part of the record, and clients can generally ask for a copy (45 CFR 164.524). Whatever software stores them should sign a Business Associate Agreement with you; you can read TranqBay's Business Associate Agreement.

Can I use abbreviations in progress notes?

Yes, if your practice keeps a written list and the ones you use can't be misread. Spell out anything ambiguous, such as "d/c," and prefer full words in any note a client or another provider is likely to read.

How detailed should a progress note be?

Specific about the clinical facts (symptoms, functioning, risk, what you did, the response and the plan) and brief about the story. Record themes rather than transcripts, and refer to other people by role.

Print it, then use it for a week

Print the one-page version, write your next five notes with it beside you, and circle the lines you reach for most. After a week you'll have your own shorter list, and notes that read the same whoever picks them up.

If you also want booking, video sessions and session notes in one place, see how TranqBay works for private practice: you can look at the practice website templates and the booking steps your clients would go through. If you're deciding whether to join, this page explains how joining TranqBay works.

Sources

8 sources

Regulations 2CMS 1Associations 2cssrs.columbia.edu 1suicidesafetyplan.com 1988 Lifeline 1

Laws and regulations2

Centers for Medicare & Medicaid Services1

3CMS, Medicare Program Integrity Manual, chapter 3, sections 3.3.2.5 and 3.3.2.6cms.govhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c03.pdf

Professional associations2

Updated October 25, 2026. Found it useful? Send it to a colleague.