Progress notes must convey that the psychiatrist provided quality care and respected the patients condition and wishes knowing what information to include and what to leave out can help you and your colleagues avoid a malpractice judgment follow these 10 dos and donts of writing progress notes 1 be concise. Use blue or black ink in writing a progress note you may also like chart note examples samples write your name legibly and include your identification as health care provider using electronic medical records to compose and blank notes is encourage guidelines for writing a progress note the following are guidelines for writing a progress . Documenting services delivered in behavioral health programs writing progress notes writing progress notes is perhaps the most common documentation activity performed by direct service providers there are two primary functions of a progress note the first function or purpose of a progress note is to record services provided by a staff member. Therapy sample notes sample mental health progress notes created in icanotes with no typing required chief complaint symptoms past mental health history medical history social history developmental history family history and mental status exam all progress notes in a compressed format optional and a final page which . This sample mental health progress note was created in 2 minutes using the icanotes mental health emr the only words typed by the clinician are highlighted in yellow
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