How to Write Progress Notes

Clear, compliant documentation that supports care, continuity, and billing.

Why Progress Notes Matter

Progress notes are the core clinical document written after each client session. They do more than summarize what happened — they demonstrate medical necessity, track progress toward treatment goals, and justify the service billed.

A strong progress note should allow another clinician, auditor, or reviewer to understand how the client presented, what clinical work occurred, and why the session was necessary.

The Documentation “Golden Thread”

  • Intake Assessment establishes baseline functioning and diagnosis
  • Treatment Plan defines goals, objectives, and medical necessity
  • Progress Notes show how each session addresses the treatment plan over time

Every progress note should clearly connect back to the diagnosis and treatment plan.

Required Elements of a Compliant Progress Note

  • Session details: date, start and stop time, location, provider credentials
  • Client presentation in session-relevant language
  • Clinical observations (mental status components)
  • Progress toward treatment plan goals
  • Risk assessment documented every session
  • Plan forward including modality, interventions, and next steps

Alignment With Tebra Notes

Tebra progress notes should be completed within the structured note template and must support the appointment type and CPT code selected.

  • Ensure start and stop times match the scheduled appointment
  • Diagnosis in the note must match the diagnosis linked to the visit
  • Risk assessment must be completed even if the client denies risk
  • Progress toward goals should reference the active treatment plan
  • Plan section should clearly state next steps or follow-up timing

If a treatment plan needs updating, document that directly in the progress note.

Common Audit Pitfalls

  • Notes that repeat the same language across sessions
  • No clear connection to treatment plan goals
  • Missing or vague risk assessment
  • Time billed not supported by documentation
  • Overly short notes for higher-level CPT codes
  • AI-generated notes not reviewed or edited by the provider

Auditors look for individualized, clinically meaningful documentation — not volume.

AI Scribes and Provider Responsibility

AI scribes can assist with documentation efficiency, but the provider remains fully responsible for the accuracy, completeness, and clinical integrity of the note.

  • Always review and edit AI-generated content
  • Ensure risk assessment is accurate and session-specific
  • Confirm the note reflects what actually occurred in session
  • Remove any content that does not apply clinically

Using an AI scribe does not replace clinical judgment or documentation responsibility.

Printable Progress Note Checklist

Use this checklist before signing your note:

  • Date of service present
  • Start and stop time documented
  • Correct place of service
  • Diagnosis referenced
  • Mental status elements included
  • Progress toward goals documented
  • Risk assessment completed
  • Interventions clearly stated
  • Plan forward documented
  • CPT code supported
  • Note signed and dated

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