Tracking a patient’s progress is a critical component of any ABA therapist’s duties. These notes not only ensure that the patient is receiving the most effective treatment options, but progress notes also play an important role in accurate coding and medical billing.
Properly composed progress notes provide critical information about the patient or group therapy session. As an ABA therapist, you can also use progress notes as a reference to adjust or modify your treatment strategy as needed.
Progress notes that are hastily written can be illegible, easily confusing, disorganized, and lack the important details your patients need. Not to mention they can be very enough difficult to translate later, which further wastes your precious time. Taking good progress notes is a skill that doesn’t always come naturally to every ABA therapist. Though there are a few important habits you can adopt to help generate progress notes that are properly organized, specific, relevant, and detailed.
The Importance of Good Progress Notes
Progress notes are more than just a record helping you to communicate findings and plans via medical and science-based facts. They contain specific elements that also need to be communicated to the patient’s insurance company, public health institutions, educators, and other clinicians. They also need to do things like note all-important state requirements, and information that might be reviewed by your licensing board and other clinicians the patient might be referred to at a later date.
Key Information To Include In Progress Notes
There are several important pieces of information that need to be represented clearly in your progress notes. This includes:
The Patient’s Information
This is more than just your client’s name, date of birth, start and end times of each session, and your signature. It also includes their payer references as well as the contact information of any physician who referred the patient to you.
The Description of the Patient’s Behavior
This is where detail can matter for some patients. It’s important to describe your patient’s behavior, including their general appearance, mood, symptoms, and diagnosis. You should also note any significant changes to their medications as well as a cursory safety assessment. You might also want to use a mental health status checklist to help consolidate this area of your notes.
Treatment Plans
This section of the patient’s progress notes needs to accurately list the treatment modalities, as well as your future recommendations. It’s best to note any improvements in their coping skills as well as any assignments you used during the session.
You need to include the client’s response as well as their progress toward any previously established goals. You should also include notes on the things you plan to work on in the following session.
The treatment plan section of the progress notes should also include any referrals you’ve made for the patient. Especially if you are collaborating with other mental health or medical professionals regarding the patient’s care.
Tips For Composing Progress Notes
Ideally, your progress notes should be written with information that can be validated or justified through clinical evidence and investigation. They are not meant for subjective description and prose.
There shouldn’t be any references to your subjective opinion, judgments, feelings, or abstract hypotheses. The notes should only contain precise descriptions of what you observed during the session in the context of your professional opinion.
In some instances, you might need to make an exception in your notes, such as if your client brings up a critical incident, they note a significant change in something that affects their treatment or they indicate in any way that they might be at risk to harm to themselves or others.
Progress Note Documentation Styles
There are a few different documentation styles to consider when composing accurate progress notes. Though there are four styles that are predominant. Using one of the following four styles will help you communicate important patient information to other clinicians and payer organizations.
DAP
DAP stands for Data, Assessment, and Plan format.
Data needs to include evidence-based descriptions of major events as well as topics that were discussed and any sort of intervention techniques that were provided. This information needs to be objective and relevant. You should include behaviors, actions, and descriptions from the patient that may affect their treatment methods.
Assessment is the section where you include your observations of your patient’s status and functioning. This might include things like risk status.
Plan includes information on future changes or continuations in the treatment plan. It might also include recommendations, alternative treatments, homework assigned, and additional resources.
SOAP
SOAP stands for Subjective, Objective, Assessment, and Plan
Subjective data needs to remain free of your unsourced personal opinions and judgment statements. This is where you would list a patient’s direct quotes, experiences, feelings, thoughts, or observations.
Objective data is where you note the patient’s general and mental health status and other relevant details from your therapy appointment.
Assessment information is where you collect all of your subjective and objective details in a way that puts forth your professional interpretation and a summary of your patient’s diagnosis.
Plan is where you note the next steps or adjustments to the patient’s treatment strategy. This is also where you would note any follow-up information, referrals, lab orders, review of medications, and your plan for your next therapy session.
BIRP
BIRP notes are used to indicate Behavior, Intervention, Response, and Plan.
Behavior needs to clearly document the primary complaint or salient problem the patient themselves presents. This can include information about their actions, willingness to participate, and observations of their behavior.
Intervention is where you provide a detailed account of the methodology used to intervene with the problem that helped the patient reach their treatment goals.
Response indicates the patient’s response as well as any key information about reaction to your intervention techniques. This might include proposed changes to their treatment plan.
Plan is where you need to note your intentions for the next treatment session or any referrals you have made to other specialists.
Conclusion
Properly composed progress notes are about far more than just jotting down some key details during a session. They represent a firm foundation for accurately developing the patient’s treatment strategy as they meet new milestones or face challenges meeting current milestones.
At the same time, progress notes also communicate the services rendered to payer organizations. They also transmit critical information to other clinicians who might see the patient in the future, or as part of an active referral from you.
