Therapy Progress Note Template and Drafting Guide

A strong therapy progress note focuses on the intersection of the treatment plan and the current session. Essential sections include the patient's presenting mood and affect, specific interventions used (such as CBT or DBT techniques), the patient's response to those interventions, and a clear update on progress toward established therapeutic goals. Documentation should avoid vague descriptors, instead favoring observable behaviors and direct quotes that justify the clinical necessity of the session.

Using an AI medical scribe eliminates the need to manually fill out a PDF template from memory hours after a session. By recording the encounter, Aduvera captures the nuance of the therapeutic alliance and specific clinical milestones in real-time. This allows the clinician to shift from recalling details to reviewing a high-fidelity draft, ensuring that the final note accurately reflects the session's complexity while remaining concise and EHR-ready.