What do you include in a progress note?
Anonym
I would write in any updates with medications, diagnoses, significant life changes at home (divorce, starting a job, etc.). Secondly, I would start with where we left off with the last progress note and ask follow up questions from the last meeting. I would finish by adding important information and any new/updated goals to work on. To continue rapport building, I would add small tidbits of personal information about the client (i.e., favorite color or song) to follow up with next time to show that I care about what's important to them.