Progress notes are the running record of what happens in care, written visit after visit, that turns a series of appointments into a coherent clinical story. They're also the documentation most clinicians complain about the most: repetitive, time-consuming, and somehow never finished by the time the day ends.

This guide fixes both problems. You'll get free, copy-and-paste progress note templates (with downloadable PDFs), a step-by-step walkthrough of how to write a strong note, and complete worked examples across primary care, mental health, nursing, and physical therapy. At the end, we'll show how an AI medical scribe can write the whole note for you while you focus on the patient.

What is a progress note?

A progress note is a clinical document that records a patient's status, the care provided, and the plan going forward at a single point in their treatment. Unlike an intake or initial assessment, a progress note captures change: what's different since the last visit, how the patient is responding to treatment, and what happens next.

Progress notes are written in nearly every care setting. A primary care physician writes one at each follow-up for a chronic condition. An inpatient team writes daily notes during ward rounds. A therapist documents every session. A physical therapist tracks mobility week over week. The format varies, but the job is the same: keep an accurate, time-stamped account of the patient's journey that any member of the care team can pick up and understand.

Why progress notes matter

It's tempting to treat progress notes as a box to check. They're far more than that, and doing them poorly carries real consequences.

Continuity of care. Your notes are how the next clinician, whether a covering colleague, a specialist, or a nurse on the next shift, understands where the patient stands. A clear note means no one has to reconstruct the story from scratch.

Legal protection. Progress notes are legal documents. If a treatment decision is ever questioned, the note is the record of your clinical reasoning. The old adage holds: if it wasn't documented, it wasn't done.

Billing and reimbursement. Payers require documentation that supports the level of service billed and demonstrates medical necessity. Incomplete or vague notes are a leading cause of denied claims and failed audits. Accurate documentation also feeds accurate coding, which is why many practices now pair their notes with an AI medical coder to capture the right ICD-10 and CPT codes.

Quality and safety. Good notes let a care team track progress, spot patterns, and catch problems early, which is the foundation of better outcomes over time.

What goes into a progress note

Regardless of the format you use, most progress notes capture the same core elements:

• Identifying information: patient name, date of service, visit type, and provider.
  
  

• Subjective update: what the patient reports since the last visit: symptoms, concerns, and their own sense of how they're doing.
  
  

• Objective findings: measurable, observable data: vital signs, exam findings, lab and imaging results, validated scores (PHQ-9, GAD-7), and behavioral observations.
  
  

• Assessment: your clinical judgment: diagnosis or impression, and how the patient is responding to treatment.
  
  

• Plan: next steps: medication changes, referrals, patient education, and the follow-up interval.

The History of Present Illness (HPI) often anchors the subjective section, especially for evaluation and management visits where the level of HPI detail affects coding.

Progress note formats explained

Most clinicians don't invent a structure from scratch; they use an established format. The four most common are:

SOAP: Subjective, Objective, Assessment, Plan. The most widely used format across medicine. It moves from what the patient reports, to what you measure, to your interpretation, to the plan. Best for general medical and follow-up documentation.

DAP: Data, Assessment, Plan. A condensed cousin of SOAP that merges subjective and objective into a single "Data" section. Popular in mental health and counseling, where the distinction between reported and observed is less rigid.

BIRP: Behavior, Intervention, Response, Plan. Built for behavioral health and substance use treatment. It centers on what the patient did, what you did about it, and how they responded.

PIE: Problem, Intervention, Evaluation. Common in nursing, where documentation maps tightly to identified problems and the interventions performed.

There's no single "correct" format. Choose the one that fits your specialty and stick to it consistently, because switching formats mid-record makes notes harder for your team to read.

Free progress note templates

Below are four ready-to-use templates covering the most common scenarios. Copy any of them directly into your EHR, or download the full set as a printable, fillable PDF.

Download: Free Progress Note Templates (PDF): four formats, print- and fill-ready.

1. General medical progress note (SOAP)

PATIENT: __________________  DOB: __________  DATE: __________

VISIT TYPE: Follow-up        PROVIDER: __________________

SUBJECTIVE

Reason for visit / interval history since last appointment:

Patient-reported symptoms, changes, adherence, side effects:

OBJECTIVE

Vitals:

Exam findings:

Labs / imaging / results:

ASSESSMENT

Diagnosis / clinical impression:

Response to treatment:

PLAN

Medications:

Referrals / orders:

Patient education:

Follow-up:

2. Nursing progress note (PIE)

PATIENT: __________________  DATE/TIME: __________  RN: __________

PROBLEM

Active problem / nursing diagnosis being addressed:

INTERVENTION

Care provided, medications administered, monitoring performed:

EVALUATION

Patient response, status change, escalation if needed:

For a structured approach to gathering the objective data that feeds a nursing note, see our head-to-toe assessment checklist.

3. Mental health / therapy progress note (DAP)

CLIENT: __________________  DATE: __________  SESSION #: ______

SESSION TYPE: Individual / 50 min      CLINICIAN: __________

DATA

Client report and clinician observations (mood, affect, presentation,

content discussed, interventions used in session):

ASSESSMENT

Clinical impression, progress toward goals, risk assessment:

PLAN

Homework, focus for next session, medication coordination, follow-up:

Behavioral health notes carry extra sensitivity. Our guide on AI scribes in behavioral health covers how to document these sessions accurately while protecting the therapeutic relationship.

4. Physical therapy progress note (SOAP)

PATIENT: __________________  DATE: __________  PT: __________

SUBJECTIVE

Pain rating, functional complaints, response since last session:

OBJECTIVE

ROM, strength (MMT), gait, exercises completed, measurements:

ASSESSMENT

Progress toward functional goals, barriers:

PLAN

Exercise progression, frequency, reassessment timeline:

How to write a progress note, step by step

A strong note isn't about writing more, it's about writing the right things clearly. Here's how to build one section by section, with examples from a psychiatry follow-up.

1. Start with identifying information. Open with the basics so the note stands on its own: patient, date, visit type, and reason for the encounter.

Follow-up visit for Jane Smith, psychiatry outpatient, 02/25/2026. Ongoing management of major depressive disorder and generalized anxiety disorder.

2. Capture the subjective update. Summarize what's happened since the last visit in the patient's own framing, including adherence and side effects.

Taking sertraline 100 mg daily for 6 weeks with partial improvement in depressive symptoms. Completed 2 of 6 recommended CBT sessions. No medication side effects reported.

3. Record objective findings. Note measurable data and observations. Validated scores are gold here because they make progress trackable.

Arrived on time, well groomed, brighter affect than prior visit. PHQ-9 decreased from 16 to 12 (moderate, improving). GAD-7 down from 14 to 10.

4. Write the assessment. State your clinical judgment and how the patient is responding, not just the diagnosis.

Major depressive disorder and GAD, both showing measurable improvement on current regimen. No safety concerns; denies suicidal ideation.

5. Lay out the plan. Be specific and actionable. Anyone reading should know exactly what happens next and when.

Continue sertraline 100 mg daily. Continue fortnightly CBT. Patient to set work-life boundaries (leave office by 6 pm). Review in clinic in 4 weeks.

Progress note examples by specialty

Templates show structure; examples show how a finished note actually reads. Here are four complete notes across different settings.

Primary care follow-up (SOAP)

S: 58-year-old male here for 1-month hypertension follow-up. Reports good adherence to lisinopril, no dizziness or cough. Has reduced sodium intake and started walking 20 minutes daily. 

O: BP 134/84 (was 148/92), HR 72, BMI 29. Cardiopulmonary exam unremarkable. 

A: Essential hypertension, improving with lifestyle changes and medication. At goal trajectory. 

P: Continue lisinopril 10 mg daily. Continue diet and exercise. Recheck BP in 4 weeks; basic metabolic panel at next visit.

Mental health / therapy (DAP)

D: Client reports anxiety decreased from 8/10 to 4/10 this week. Used breathing techniques during a work presentation. Sleeping 6-7 hours (up from 3-4). Presented relaxed, good eye contact, euthymic mood. Denied suicidal ideation. 

A: Generalized anxiety disorder (F41.1). Significant improvement in symptom management and sleep. Responding well to CBT. 

P: Continue weekly CBT. Introduced progressive muscle relaxation. Homework: PMR daily for 10 minutes, continue anxiety tracking. Next session in 1 week.

Nursing (PIE)

P: Post-operative pain management, day 1 post-op. 

I: Administered ordered analgesia at 0800. Repositioned for comfort, encouraged early ambulation, monitored vitals q4h. 

E: Pain reduced from 7/10 to 3/10 within 45 minutes. Ambulated 50 feet with assistance. Vitals stable, no signs of distress. Continue current plan.

Physical therapy (SOAP)

S: Reports decreased pain with walking and improved sleep. Rates knee pain 3/10 (down from 6/10). 

O: Gait: mild residual limp, stride length improved. Left hamstring strength 4/5 (was 3/5). Completed all exercises with good form. 

A: Functional gains in strength and endurance; minor compensations improving. 

P: Advance therapeutic exercises, add single-leg balance work. Continue 3x/week, reassess ROM next week.

Common mistakes to avoid

The difference between a note that protects you and one that creates risk often comes down to a few habits. Here's what to avoid, with better alternatives:

Vague or non-specific language. A note that says the patient is "doing fine" tells the next clinician nothing.

• Wrong: "Patient feeling a bit off, follow up in two weeks."
  
  

• Correct: "Patient reports intermittent fatigue and poor sleep over the past week; PHQ-9 unchanged at 12."

Personal judgments. Document behavior and clinical facts, never character assessments.

• Wrong: "Patient seems lazy and unmotivated."
  
  

• Correct: "Patient reports difficulty maintaining exercise routine due to fatigue."

Speculation as fact. Stick to what you observed and what the patient reported.

• Wrong: "Patient is probably exaggerating the pain."
  
  

• Correct: "Patient reports pain 10/10; no objective signs of acute distress observed."

Copy-paste errors. Carrying forward a prior note without updating it is one of the most common audit findings and a genuine patient-safety hazard. Verify every cloned line.

Notes that are too long. Over-documentation buries the signal. Capture what's clinically relevant to this encounter, not everything that was said.

Tips for writing progress notes faster

1. Use a template every time. Don't rebuild structure on each note. Standardizing your format is the single biggest time-saver.
   
   

2. Write notes the same day. A backlog of notes is overwhelming and less accurate. The details fade fast.
   
   

3. Keep it concise and scannable. Short, factual statements beat long paragraphs. Write for the colleague who has 15 seconds.
   
   

4. Be consistent. Pick one format per note type and don't deviate mid-record.
   
   

5. Let AI handle the first draft. Ambient documentation tools now generate a structured, formatted note from the visit conversation, turning note-writing from a 10-minute chore into a 30-second review.

Automate your progress notes with Sully.ai

Even the best template still leaves you typing during or after the visit. That's the problem an AI scribe solves.

Sully.ai's AI Scribe listens to the patient encounter and produces a structured, HIPAA-compliant progress note in seconds, in the format you use, whether that's SOAP, DAP, BIRP, or a custom specialty template. Instead of writing notes, you review and approve them, with the clinician in control at every step.

Because Sully.ai works inside your existing systems through deep EHR integrations with Epic, Oracle Cerner, athenahealth, and dozens more, the finished note lands where it belongs without copy-paste or app-switching. It's part of a broader move toward clinical workflow automation that's giving clinicians their evenings back. To learn more about the technology behind ambient documentation, see our guide to medical voice AI.

The result: less after-hours charting, fewer denied claims from incomplete notes, and more attention on the patient in front of you.

Frequently asked questions

What is a progress note? 

A progress note is a clinical document recording a patient's status, the care provided, and the plan at a single point in their treatment. It captures what has changed since the last visit and serves as a legal record, a communication tool, and the basis for billing.

What's the difference between a progress note and a psychotherapy note? 

A progress note is part of the official medical record and documents the clinical course of treatment. A psychotherapy (or "process") note contains the therapist's private analysis of a session and receives special protection under HIPAA; it is kept separate from the medical record and is not shared with payers.

What are the four parts of a SOAP note? 

Subjective (what the patient reports), Objective (measurable findings and observations), Assessment (your clinical judgment and diagnosis), and Plan (next steps for treatment and follow-up).

How long should a progress note be? 

Long enough to capture everything clinically relevant to the encounter and no longer. A focused follow-up note may be a few sentences per section; a complex visit will be longer. Conciseness and completeness matter more than length.

Are progress notes legal documents? 

Yes. Progress notes are part of the legal medical record. They can be subpoenaed, audited by payers, and used to demonstrate the care that was provided and the reasoning behind it.

What's the best format for a progress note? 

It depends on your setting. SOAP is the most versatile and widely used; DAP and BIRP are common in mental and behavioral health; PIE is common in nursing. The best format is the one that fits your specialty and that you can apply consistently.