What goes in a counseling progress note?

[@EricKebela]

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

[@wendychan1111]

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

[@Jodi_EmpowerHerTransformation]

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]

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

[@wiccanreade]

Thank you for the details and clarity.

[@Margot-c6z]

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

[@dr.t2027]

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]

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.

[@barbgris]

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]

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 :)

[@rubengonzalez5299]

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

[@catherineshreenan1514]

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

[@MaelisaMcCaffrey]

You’re welcome!

[@MariaRowsell]

This is very helpful - thank you!

[@Cloudss9]

Thank you Maelisa!!

[@mayralopez8052]

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

[@MaelisaMcCaffrey]

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

[@staciamj1]

Great info!

[@lbg87]

Hi, I'm wondering if you have an example of a response section for a BIRP or GIRP note. I might have missed this if it was addressed in this video. (I recently also bought your "stress-free documentation" book and I was also wondering if/where there are examples of the response section for a BIRP or GIRP note?).

[@MaelisaMcCaffrey]

I don't usually recommend just a Response section. Instead, I break it up into categories that are easier to complete. Check out the note templates in the online resources for the book! You'll see what I mean with examples and a few template options :)

[@marianaperalta2581]

So helpful. Thank you 🙏🏼

[@yvettesilas5648]

Thank you very helpful

[@AmyAlves-n8y]

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]

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]

Thank you

[@shariecebrewster5962]

I am need your information as well

[@shariecebrewster5962]

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[@lavleeable]

Pm