Mastering Progress Notes: Improve Content, Efficiency, and Compliance

Whether called case notes, encounter notes, or progress notes, documenting service delivery is a universal aspect of care from psychotherapy to case management. It helps us organize and track our treatment progress and serves as the primary documentation of our high-quality care that keeps us accountable to both clients and payors. It’s also time-consuming, confusing, and the most-commonly audited part of the clinical record, which creates legal and financial risk for our practice. 

This interactive live web training is designed for both new and experienced practitioners who wish to improve the quality and efficiency of their service documentation. It will simplify the competing demands and best practices of progress notes to help improve the quality of your documentation skills and your ability to organize and track progress of your treatment.

Learning Objectives:

  1. Explain how to align progress notes to the treatment plan and use them to measure progress

  2. List common audit triggers, fraud risks, and reasons for payback

  3. Describe standard progress note formats and required elements

  4. Compose comprehensive person-centered progress notes

Target Audience:

Human services practitioners including social workers, counselors, case managers, psychotherapists, clinical supervisors, and quality improvement staff

  • Introduction (10 minutes)

    • Learning objectives, lesson agenda

    • Course expectations/interactivity

    Lesson 1: Purpose of Progress Notes (10 minutes)

    • Purpose of progress notes

    • Progress notes versus psychotherapy notes

    Lesson 2: Compliance and Practice Standards (45 minutes)

    • Auditors & regulators: Payors

    • Other practice standards

    • Medical necessity

    • Exercise: What are auditors looking for?

    • Common audit issues

    • Exercise: Auditing a note

    Lesson 3: Progress Note Formats and Required Elements (35 minutes)

    • Freeform narrative, SOAP, DAP, GIRP, BIRP, PIRP, SIRP

    • Pros/cons of each format

    • Common elements of all formats

    • Exercise: GIRP note example

    Break (15 minutes)

    Lesson 4: Additional Best Practices (25 minutes)

    • Person-centered care

    • Exercise: Person-centered language

    • Improving note efficiency

    • Additional progress note tips

    Lesson 5: Progress Note Writing Exercise (45 minutes)

    Course Summary (10 minutes)

Instructor: David Shapiro, LICSW

CE Credits: 3

Mastering Progress Notes: Improve Content, Efficiency, and Compliance, Course #4552, is approved by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program to be offered by Shapiro Training & Consulting as an individual course. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE course approval period: 11/29/2022 - 11/29/2024. Social workers completing this course receive 3 Clinical continuing education credits.

States that accept ASWB ACE approved continuing education.