What goes in a counseling progress note?

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Therapy progress notes cover many topics and it’s confusing deciding what to add and what to leave out! In this video, Dr. Maelisa McCaffrey of QA Prep explains what sections to include in any progress note.
It doesn’t matter if you use SOAP notes, DAP notes, BIRP notes or GIRP notes. There are still some common things you always want to include in your counseling case notes. Watch the video to learn more.
If you want a plug and play therapist paperwork packet, you can click here to check it out: www.qaprep.com/paperwork-packet
Still need help with your mental health documentation? Check out the FREE Private Practice Paperwork Crash Course here: www.qaprep.com/crash-course

Опубликовано:

20 июл 2024

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Комментарии : 25

@user-tj3wm6xf6u 3 месяца назад

Thank God that I came across your videos and teachings. Thank you, Doc.

@takebackmylifetakemylifeba8362 Год назад

I would love an example of writing a progress sentence (what progress that client has made and what they still need to work on ) when it is a "worried-well" client. Example: The client may be continuing to process family of origin dynamics and continue to need feedback from the therapist about how to handle situations. Each week's note may look the same/ similar even though the client is making small shifts.

@MaelisaMcCaffrey Год назад

Small shifts, or even documenting regression, is totally fine! Just make sure you're addressing the goals and symptoms related to the diagnosis.

@wendychan1111 Год назад

Thank you for making these videos! Cant wait to watch all your other offerings on youtube.

@MargotLemaire Год назад

This is extremely helpful. Thank you for your work and generosity!

@wiccanreade Год назад

Thank you for the details and clarity.

@rubengonzalez5299 11 месяцев назад

Simple and to the point! Very helpful tips. Thanks!

@barbgris Год назад

Melisa, This was great but I would argue that including client's Symptoms and Impairment are more important than client presentation. Symptoms and impairment help defend your diagnosis and to defend medical necessity for treatment, both which are essential for insurance reimbursement.

@MaelisaMcCaffrey Год назад

I agree and I think maybe we're thinking the same thing but using different language? Rather than repeat symptoms over and again, I encourage people to focus on the behaviors and affect related to the diagnosis present in each session. As well as progress/impairment, for medical necessity purposes. I think you're correct that I should have emphasized the impairment/progress portion for those billing to insurance in the U.S. Thanks for that :)

@Cloudss9 Год назад

Thank you Maelisa!!

@marianaperalta2581 Год назад

So helpful. Thank you 🙏🏼

@staciamj1 Год назад

Great info!

@catherineshreenan1514 4 месяца назад

Thank you so much for your information. It is so helpful! I really appreciate this.

@MaelisaMcCaffrey 4 месяца назад

You’re welcome!

@yvettesilas5648 Год назад

Thank you very helpful

@shariecebrewster5962 3 месяца назад

Thank you

@dr.t2027 Год назад

Any treatment ambivalence and noteworthy qualitative dynamics between the patient and therapist are important to document. Also, while patient progress is important to document, progress does not happen during every session, as most therapists can attest to. Do you recommend statements that indicate that progress has remained the same since previous sessions ?

@MaelisaMcCaffrey Год назад

Regarding progress or lack thereof... absolutely! It's perfectly fine to honestly document when no progress has occurred in a week, or even when someone has regressed. Therapy is not linear. The key is to check in about this if it becomes an ongoing pattern.

@mayralopez8052 7 месяцев назад

Hello I looooove your videos. Does the paperwork packet include GIRP notes?

@MaelisaMcCaffrey 7 месяцев назад

Yes, but it also has my progress note template which incorporates some other aspects while simplifying things more 😊

@user-fm2su1yx9m 6 месяцев назад

Hi Maelisa, Thank you for making these videos. As someone with ADHD who hyperfixates on things like this, it's helpful to have concrete steps. I have one question- are you suggesting that a narrative section on a progress note is not necessary? It sounds like you're saying most of these can be written in list, bullet point, or check box form. I'm not sure where I heard that there needs to be some sort of narrative as well for insurance companies to be happy. Any insight on this?

@MaelisaMcCaffrey 6 месяцев назад

Even a narrative section could just have bullet points! So yes, I’m saying you don’t need to write in full sentences or paragraphs. And for most sections, you can have pre-created but detailed checkboxes. :)

@shariecebrewster5962 3 месяца назад

I am need your information as well

@shariecebrewster5962 3 месяца назад

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