A progress note should include which of the following?

A progress note should include which of the following?

• A. Just the date of the session
• B. Overall client satisfaction
• C. Actual events, important client statements, and dates
• D. Client goals only

Answer: (C)

A progress note serves as a detailed, factual record of interactions with a client and is an essential component of behavioral health documentation. It should capture actual events that occurred during the session, important statements made by the client, and relevant dates to build a comprehensive picture of the client's progress and treatment. This information is critical for maintaining continuity of care, facilitating communication among team members, and ensuring that all stakeholders have access to accurate information regarding the client's journey. Including details about significant events and client statements allows for an accurate assessment of the client's needs, thoughts, and feelings, which can lead to more effective treatment planning. The documentation must be thorough and reflect what transpired, thereby providing critical insights for future sessions. In contrast, merely noting the date of the session does not provide useful information for ongoing care. Focusing solely on overall client satisfaction lacks the specificity needed for clinical decision-making. Documenting only client goals neglects the important context of interactions and developments that are crucial to understanding the client’s progress.

A progress note serves as a detailed, factual record of interactions with a client and is an essential component of behavioral health documentation. It should capture actual events that occurred during the session, important statements made by the client, and relevant dates to build a comprehensive picture of the client's progress and treatment. This information is critical for maintaining continuity of care, facilitating communication among team members, and ensuring that all stakeholders have access to accurate information regarding the client's journey.

Including details about significant events and client statements allows for an accurate assessment of the client's needs, thoughts, and feelings, which can lead to more effective treatment planning. The documentation must be thorough and reflect what transpired, thereby providing critical insights for future sessions.

In contrast, merely noting the date of the session does not provide useful information for ongoing care. Focusing solely on overall client satisfaction lacks the specificity needed for clinical decision-making. Documenting only client goals neglects the important context of interactions and developments that are crucial to understanding the client’s progress.