A mental health progress note records what happened in a session and why it matters clinically: the client's presentation, the intervention you used, how they responded and your plan for next time. Write it soon after the session, keep it factual, and use a consistent format like SOAP, DAP or BIRP so it stays easy to defend.
What is a mental health progress note?
A progress note is the contemporaneous record of a single clinical contact. It is not a transcript and not a personal diary. It captures the clinically relevant facts of the session so that you, a supervisor, or another clinician can understand the client's care and continue it safely.
Good progress notes do three jobs at once. They support continuity of care, they meet your professional and legal record-keeping obligations, and they give you a running picture of whether treatment is working. If you keep separate psychotherapy and clinical progress notes, the progress note is the shareable clinical record, distinct from your private process notes.
What should every mental health progress note include?
Regardless of format, a defensible mental health progress note covers:
- Session details. Date, time, duration, modality (in person or telehealth) and who attended.
- Presentation and mental state. How the client presented, relevant mental state observations, and any change since the last session.
- Risk. A clear statement on risk to self or others. If risk is present, document what you assessed and what you did. If it was screened and nil, say so.
- Intervention. The therapeutic approach or techniques used, framed against the treatment goals.
- Response. How the client engaged with and responded to the intervention.
- Plan. Next steps, homework, referrals, and the date or focus of the next session.
The Psychology Board of Australia expects practitioners to keep accurate, legible and contemporaneous records under its professional standards and guidelines; other disciplines have equivalent requirements. Documenting risk explicitly, every session, is the single most important habit.
What format should you use: SOAP, DAP or BIRP?
There is no mandated format. Pick one and apply it consistently. The three most common in mental health are:
- SOAP (Subjective, Objective, Assessment, Plan): the most widely used, strong for medical and multidisciplinary settings.
- DAP (Data, Assessment, Plan): a leaner structure that folds subjective and objective into a single data section, popular in counselling.
- BIRP (Behaviour, Intervention, Response, Plan): intervention-focused, common in mental health and case management.
For a full breakdown of when to use each, see our guide to the types of clinical notes and the complete SOAP notes guide.
Mental health progress note examples
The examples below are illustrative and do not describe real clients.
SOAP note example (generalised anxiety)
S: Client reports ongoing worry about work, sleep onset delayed to around 90 minutes, describes mood as "on edge". Denies suicidal ideation. O: Alert, cooperative, mildly restless. Speech normal rate. Affect anxious, congruent. No evidence of thought disorder. Risk screened, nil concerns. A: Symptoms consistent with generalised anxiety, partial response to CBT. Engagement good; sleep remains the priority target. P: Introduced worry postponement and sleep hygiene plan. Client to complete a thought diary. Review in one week.
DAP note example (low mood)
D: Client attended on time via telehealth. Reports flat mood most days, reduced interest in usual activities, appetite low. Completed DASS-21 (depression subscale in moderate range). Risk screened, nil current ideation or plan. A: Depressive symptoms stable to mildly improved on behavioural activation. Motivation remains a barrier. P: Agreed two small activity goals for the week. Continue behavioural activation. Provide GP update. Review in two weeks.
BIRP note example (panic)
B: Client described two panic episodes this week, both at the shopping centre, with avoidance since. I: Reviewed panic cycle, practised interoceptive exposure in session, planned graded exposure hierarchy. R: Client engaged well, anxiety reduced from 8/10 to 4/10 during in-session exposure. P: Client to complete first two exposure steps before next session. Review hierarchy next week.
A reusable mental health progress note template
Copy and adapt this structure:
- Date / time / duration / modality:
- Attendees:
- Presentation and mental state:
- Risk (self / others / screened nil):
- Focus of session (goal addressed):
- Intervention used:
- Client response:
- Plan and next session:
- Clinician name and signature:
Sending outcome measures through digital forms and assessments means scores like the K10 or DASS-21 land in the record automatically, so your notes reference live data rather than a half-remembered number.
What are the common mistakes to avoid?
- Writing too late. Memory fades fast. Complete the note the same day.
- Vague language. "Client seemed better" is not defensible. State what you observed and what changed.
- Omitting risk. A note without a risk statement reads as if risk was never considered.
- Copy-pasting the last note. Cloned notes undermine the record and can mislead the next clinician.
- Blurring process notes into the clinical record. Keep private reflections separate.
- Over-writing. A tight, relevant note beats a long one. Aim for clinically necessary, not exhaustive.
How can AI speed up mental health progress notes?
Documentation is one of the biggest drivers of clinician admin load, and it is where AI now helps most. PractaLuma is AI-native practice management software for Australian mental-health practices, so an AI scribe can draft a structured note in your chosen format straight from the session, ready for you to check.
The rule that protects the record is clinician control: AI drafts, the clinician reviews, edits and approves before anything is saved or shared. Notes stay inside your clinical notes workspace, not scattered across documents. For a closer look at how AI-assisted documentation works in practice, read our guide to AI patient notes, and see pricing if you want to trial it.
Frequently asked questions
How long should a mental health progress note be?
Long enough to capture the clinically relevant facts and no longer. Most session notes fit in a short paragraph per section. Prioritise presentation, risk, intervention, response and plan over narrative detail.
What is the difference between a progress note and a process note?
A progress note is the formal clinical record of the session and is shareable and subject to record-keeping rules. A process note is your private reflection, kept separately and to a higher confidentiality bar. Do not merge the two.
Do I have to document risk in every note?
Yes. Record a risk statement each session, even when risk is nil. Documenting that you screened and found no concerns is far safer than silence, which reads as though risk was never considered.
How long must I keep mental health records in Australia?
Retention varies by state and client age. Adult records are commonly kept for at least seven years from last contact, and records of children are kept longer, often until the client's mid-twenties. Check your state legislation and professional guidelines, and store records securely for the full period.
Which note format is best for mental health?
There is no single best format. SOAP suits multidisciplinary and medical settings, DAP suits counselling, and BIRP suits intervention-focused mental health work. Choose one and apply it consistently across your practice.
Progress notes are a skill that compounds. A clear, consistent format, an unwavering habit of documenting risk, and software that drafts the routine parts for you turn note-writing from an after-hours chore into a few reviewed minutes between sessions.