Progress notes are one of the most important (and often time-consuming) parts of psychological practice. Whether you are working in private practice or a multidisciplinary team, well-written notes ensure clinical continuity, and protect both the patient and clinician.

In this guide, we’ll cover why progress notes matter, what to include, common mistakes, and how modern tools like AI can support the process, without compromising professional standards.

Why Progress Notes Matter

Progress notes are more than just an administrative task. Importantly, they:

• Document the clinical journey and treatment plan.

• Reflect the progression of therapy over time, including interventions and patient response.

• Record clinically significant observations, including risk.

• Serve as legal and ethical protection for both clinician and patient.

In a multidisciplinary setting, notes also support continuity of care. When another practitioner reviews your notes, they should be able to clearly understand what was happening in therapy, what was being offered, and how the patient was progressing.

In private practice, while others may not see the notes, they remain critical—especially in the event of a subpoena, ethical review, or complaint. Well-written notes help justify clinical decision-making and demonstrate a clear rationale for treatment.

What Should Be Included in a Progress Note?

While the content of a progress note will vary depending on therapeutic style (for example, CBT vs psychodynamic approaches), some core elements should appear in every note:

1. Session Details

   • Date, time, format (in-person, telehealth).

   • You can also include a line about the service, for example: 50-minute individual psychological therapy appointment

2. Mental State Observations

   • Comments on the patient’s mental state. See this guide by the Royal Children’s Hospital for a great reference that you can have on hand.

3. Session Focus

   • Assessment, treatment planning, or active intervention.

   • Always reference the therapeutic modality used.

4. Session Content Summary

   • A non-verbatim outline of the key themes and clinical work.

   • Avoid sensitive disclosures or deeply personal content unless clinically necessary.

   • Include the time that the appointment ended.

5. Progress and Planning

   • Whether the patient is moving toward therapeutic goals.

   • Depending on the therapeutic modality, you may include a plan for the next session, including any assigned tasks (particularly for structured therapies like CBT).

6. Risk Assessment

   • A note on risk is essential. Every session should reference this, even if only to note that there are no observed concerns. If there are concerns, a plan should be documented.

Example: Basic Progress Note

50-minute individual psychological therapy appointment

Session Details

• Date: 21 April 2025

• Location: In-person

• Session Number: 40

• Mental Health Care Plan: 6/10

Mental State Examination

• Patient appeared somewhat dysthymic, with flat and constricted affect.

Session Focus

• Develop interpersonal functioning, emotional expression, and self-awareness using a psychodynamic approach.

Session Content

• The patient used the appointment to discuss and explore difficulties related to a recent interpersonal conflict at work. We explored themes of anger and guilt, and considered this in the context of early life experiences.

• The appointment ended at 4.50 pm.

Progress

• The patient demonstrated increased capacity to explore difficult emotional experiences.

Plan

• Continue with regular appointments.

Risk

• No significant concerns were raised.

Common Mistakes in Progress Notes

After several years of clinical work and supervision, there are some common difficulties that seem to be experienced by most psychologists and mental health professionals:

Writing too much

A progress note is not a transcript. Overly long notes can be both clinically inappropriate and ethically risky, particularly when they include highly sensitive material.

Writing too little

Minimal notes (e.g., session details and one sentence) provide no insight into clinical reasoning or treatment direction. They leave the clinician exposed if the notes are ever reviewed.

Being overly subjective

Progress notes should report observations and session content—not speculative interpretations or personal impressions. If you wouldn’t feel comfortable sharing the note with your patient, it likely needs revision.

Handwritten notes

A common issue is relying solely on handwritten notes, whether on paper or written electronically. While handwritten notes can feel quick and convenient at the time, they often fall short of professional standards.

In many cases, handwritten notes become difficult—if not impossible—for others to interpret. Acronyms, arrows, abbreviations, underlining, and personal shorthand may make sense to the original writer, but for anyone else reviewing the file (a colleague, supervisor, regulatory board, or legal representative) the notes can be unclear and unusable.

It’s not enough to assume “I know what I meant.” Progress notes should be written clearly enough that another professional could understand the course of therapy and the rationale for your clinical decisions—even without the benefit of direct context.

Copy-paste habits

Repeating the same note week after week, even with minor edits, creates unclear documentation, and fails to reflect meaningful therapeutic work.

A well-balanced note is structured, succinct, clinically relevant, and professional.

Can AI Help Psychologists With Note Writing?

AI is increasingly part of modern clinical practice, from administrative tasks to documentation. But not all AI tools are created equal.

Some clinicians experiment with AI scribes that record entire sessions and auto-generate notes. While this may seem efficient, there are clear risks:

• It can intrude on the therapeutic process, even if the patient has provided consent.

• Subtle but significant changes in patient disclosure patterns can occur when conversations are recorded.

• Ethical and privacy concerns around storage, especially with sensitive material.

For many psychologists, a middle ground is emerging:

AI-powered tools like NoteMate allow you to dictate your observations after the session and convert them into high-quality progress notes—without recording therapy sessions or storing sensitive information.

NoteMate was built specifically for Australian psychologists and offers:

• No data storage—your notes stay on your device.

• Templates aligned with Australian clinical practice.

• Improved consistency and reduced admin burden.

• A workflow that supports reflective thinking, rather than intrusive recording.

Final Thoughts

Progress notes are a cornerstone of ethical and effective psychological practice. Writing them well requires clarity, structure, and clinical relevance—not unnecessary length or speculation.

Modern AI tools can help streamline note writing, however, it is essential to choose solutions that respect therapeutic boundaries, protect patient privacy, and reduce, rather than increase administrative stress.

This article is intended as a general guide based on professional experience, and is not a substitute for clinical training, supervision, or formal policy. Psychologists and mental health professionals must always apply their own clinical judgment, and ensure that their documentation practices meet the standards required by their professional body, workplace, and applicable legislation.