Progress and Process Notes

[Page 2673]A progress or process note is a document that provides a record of what was done within a clinical setting. It serves as a summary of the clinical contact, and the clinician can refer to it to recall what happened in prior sessions. It is also helpful for determining ongoing progress and to maintain a consistent approach in treatment. Notes are written with the expectation that if another clinician had to fill in for the writing clinician, there would be enough information in the notes that the new clinician would understand what had occurred in previous sessions. This is especially important in a setting where multiple clinicians work with the client. Progress and process notes are written in such a manner that if a ...