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By far the most widely used of these templates is known as SOAP. SOAP notes separate the information into four different categories: Subjective, Objective, Assessment, and Plan.
Progress notes record the date, location, duration, and services provided, and include a brief narrative. Documentation should substantiate the duration and frequency of service delivery. The narrative should describe the following elements: Clients symptoms/behaviors.
Progress notes document a clients presentation, diagnosis, treatment plan, and progress towards achieving their therapeutic goals. Written and accessible by all the patients healthcare providers, in addition to third parties and social workers.
Tabers medical dictionary defines a Progress Note as An ongoing record of a patients illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note.