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The 3 things that help therapists finish progress notes faster

Learn more about how you can boost your efficiency with documentation.

Your progress notes are an integral part of the services you provide as a therapist. Yes, the actual session is critical for mental health care — but proper documentation, including progress notes, enable you to provide the best possible support to your clients over time. 

For example, progress notes ensure you’re staying on track toward meeting therapeutic goals so you can change course if needed. And if you’re working with insurance, then progress notes are an important piece of content to ensure you get reimbursed for your work.

As important as progress notes are, this kind of documentation can be time-consuming — and you may be wondering how to finish progress notes faster. Below, learn more about how you can boost your efficiency with documentation (and ultimately, be a better therapist to your client base).

Remember your audience.

Faster progress notes aren't just about speed. Understanding the point of these notes can ensure you do them correctly the first time, reducing the odds of needing to revisit the documentation in the event of a payer audit. 

When you write progress notes, it may be tempting to simply report on what happened in session — what you and your client talked about and how their mood seemed that day, for example. 

While these can be helpful details, narrative storytelling isn’t necessarily the point of this documentation. The goal is to show the progress your client’s making toward their goals. 

“We need to adopt a mindset of observation and justification,” says Madison Hamm, a psychotherapist with Grace Therapy & Wellness in Austin, Texas. “It should be more of an evaluation and assessment mindset rather than simply regurgitating what happened in the office.”

Cut the fluff.

Documentation should always be thorough, but also precise — meaning, you should only include the details necessary to show insurance payers why the care you’re providing is important for a person’s care. (The more fluffy parts can still remain in your own notes, of course, but for the sake of submitting documentation to insurers, they should be cut.)

When you understand the lens through which to write your progress notes, you’ll inevitably save time on them. “Thinking about my target audience allows me to cut out unnecessary fluff in documentation,” says Hamm. 

Instead of a stream-of-consciousness approach that outlines the entire session from start to finish, try to focus on the most meaningful details about the session that show you whether your client is making progress toward goals — as well as how their symptoms and level of functioning are changing and improving. This way, insurance payers know why the care is necessary for your client’s well-being. 

Typically, Hamm says, insurance payers want to know what’s happening in relation to your diagnosis or presenting problem for which someone is seeking therapy.

Use a template.

Finally, to streamline the process of finishing progress notes, it helps to use the same structure each time. Knowing what to include and in what order can save time and keep your notes on topic. Hamm says she primarily uses SOAP notes, but you can also use DAP notes or BIRP notes — whichever option you find works best for your documentation workflow. 

“It can help to know what to include beforehand instead of spending ten minutes racking your brain about what happened in the session and what to write about,” Hamm says.

Headway is a free service that makes it easier and more profitable for therapists and psychiatrists to accept insurance.

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Why you should consider accepting insurance