COMMON ELEMENTS: There are some “subjective” preferences that counties or reviewing entities may require in a progress note, but common standards include: Include all of the elements required by Title 22—Names/signatures; dates; topic of service Document progress toward Treatment Plan Goals and/or emergence of conditions that may require adjustments to the treatment plan—reference ASAM Dimension Summarize and be succinct—avoid overworked narrative, descriptive notes that detail what was observed but provide little or no information on interventions or actions taken. Use a standard of documentation (see formats below) FORMATS: There are number of acceptable formats for progress notes. Three common formats are (see the table below and Appendix 1-3): S.O.A.P B.I.R.P. D.A.P. S (Subjective)- The data gathering B (Behavior)- Subjective data D (Data)- Subjective and section that contains information from about the client [key Objective data about the the patient; key words and brief statements] and Observations session; include type of statements the patient says which made by the counselor [factual, session(s) attended. summarize the theme of the session measureable, and observable data) O (Objective)- Factual, measureable and observable data A (Assessment)- Summary of the I (Intervention)- Methods used A (Assessment)- Summary of counselor’s clinical thinking regarding to address goals and objectives the counselor’s clinical the data from the “S” and “O” portion including content and process thinking regarding the data of the notes. Include goals, objectives, of session from the “S” and “O” portion and interventions addressed in the of the notes. Include goals, R (Response)- Response to session and patient’s objectives, and interventions intervention and progress response/progress. addressed in the session and toward goals and objectives patient’s response/progress. P (Plan)- Plan for future work; reflect P (Plan)- Documenting what is P (Plan)- Plan for future work; follow-up needed or completed planned for future work reflect follow-up needed or completed
COMMON ELEMENTS: There are some “subjective” preferences that counties or reviewing entities may require in a progress note, but common standards include: Include all of the elements required by Title 22—Names/signatures; dates; topic of service Document progress toward Treatment Plan Goals and/or emergence of conditions that may require adjustments to the treatment plan—reference ASAM Dimension Summarize and be succinct—avoid overworked narrative, descriptive notes that detail what was observed but provide little or no information on interventions or actions taken. Use a standard of documentation (see formats below) FORMATS: There are number of acceptable formats for progress notes. Three common formats are (see the table below and Appendix 1-3): S.O.A.P B.I.R.P. D.A.P. S (Subjective)- The data gathering section that contains information from the patient; key words and brief statements the patient says which summarize the theme of the session B (Behavior)- Subjective data about the client [key statements] and Observations made by the counselor [factual, measureable, and observable data) D (Data)- Subjective and Objective data about the session; include type of session(s) attended. O (Objective)- Factual, measureable and observable data A (Assessment)- Summary of the counselor’s clinical thinking regarding the data from the “S” and “O” portion of the notes. Include goals, objectives, and interventions addressed in the session and patient’s response/progress. I (Intervention)- Methods used to address goals and objectives including content and process of session A (Assessment)- Summary of the counselor’s clinical thinking regarding the data from the “S” and “O” portion of the notes. Include goals, objectives, and interventions addressed in the session and patient’s response/progress. R (Response)- Response to intervention and progress toward goals and objectives P (Plan)- Plan for future work; reflect follow-up needed or completed P (Plan)- Documenting what is planned for future work P (Plan)- Plan for future work; reflect follow-up needed or completed