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A psychotherapy progress note is the session-by-session record of psychotherapy in the standard clinical chart: how the client presented, the interventions used, the response, and the plan. Despite the similar name, it is legally distinct from HIPAA's separately kept psychotherapy notes. Most therapy progress notes run 100 to 350 words.
Therapists, psychologists, counselors, clinical social workers, psychiatric prescribers
Treating clinician, care team, supervisors, payers, auditors
100 to 350 words · 10 to 20 minutes by hand (clinical team estimate)
Umbrella progress-note record (SOAP, DAP, BIRP, and narrative are common structures)
After every psychotherapy session, in the standard clinical record
Content is regulated (privacy status, retention, payment support); the structure itself is convention
A psychotherapy progress note documents one psychotherapy encounter: what was addressed, how the client presented, which interventions you used, how the client responded, and what happens next. Unlike SOAP or DAP, it is not a named format with a single inventor. "Progress note" is the umbrella record type, and SOAP, DAP, BIRP, and narrative notes are all common ways to structure one. What regulators and payers govern is the note's content, privacy status, retention, and payment support, not its headings.
The naming trap matters more here than on any other note type. Under HIPAA, "psychotherapy notes" are a narrow legal category: the therapist's private process notes, kept separate from the rest of the chart. That definition expressly excludes medication information, session start and stop times, modality and frequency, test results, and summaries of diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Those excluded items are exactly what belongs in a progress note. So the note you write after each session, the one this page covers, is part of the standard record no matter what your EHR labels it, and labeling it a "psychotherapy note" does not give it HIPAA's special protection (see the psychotherapy notes authorization page).
Every licensed clinician delivering psychotherapy keeps one per encounter: therapists, psychologists, counselors, clinical social workers, and psychiatric prescribers documenting therapy time. When insurance is involved, the progress note is where medical necessity lives session to session. Medicare's outpatient psychiatric criteria expect documentation that connects each service to an individualized written treatment plan with expected goals. The structure is your choice: SOAP, DAP, BIRP, or a clean narrative all satisfy the same content expectations when the required elements are present.
Each element in more detail, with the pitfall that shows up in federal audit findings:
1: Frame the encounter. Identify the client, date, service, and time support for the billed code. Pitfall: psychotherapy time not documented; missing time is a named cause of improper payment in OIG's national psychotherapy audit.
2: Presentation and status. What you saw and measured: presentation, mental status highlights, scores (PHQ-9, GAD-7), stressors, and changes since last session. Pitfall: vague global statements ("doing better") with nothing observable or measurable behind them.
3: Interventions. Name the actual techniques: cognitive restructuring, exposure with response prevention, behavioral activation, EMDR resourcing. Pitfall: "provided therapy" or "supportive counseling" alone; OIG flagged notes where therapeutic maneuvers were not specified.
4: Response and progress. Tie the session to a numbered treatment-plan goal and record the client's response and current risk status. Pitfall: no link to an individualized plan, which breaks the medical-necessity chain payers look for.
5: Plan, sign, date. Specific next steps, then authenticate: signed, dated, with credentials. Pitfall: unsigned or undated notes, or pasted images of signatures instead of controlled electronic signatures; both appear in federal audit findings.
Client: [initials] Date: Session #: Service: [type/length] Start/stop or total time: Presentation & status: Interventions provided: Response & progress toward goal: Risk status: Plan / next steps: Clinician signature & credentials: Date signed:
Free to use and share, no signup. The PDF includes a one-page cheat sheet with the audit-tested element checklist; the DOCX is the blank template, ready to adapt.
Scenario: adult client, major depressive disorder, behavioral activation with cognitive work, session 8 of a planned 16. Narrative structure. All details are fictional.
Client: F.L., 42 · Date: 07/09/2026 · Session: 8 · Service: Individual psychotherapy, 45 min, in office · Start/stop: 13:02 to 13:47
Presentation & status: On time, adequately groomed, cooperative. Mood reported as "flat but functional," rated 5/10. Affect mildly constricted, brighter when describing weekend hike. Sleep 7 hours, appetite stable. PHQ-9 today: 11 (down from 18 at intake, 13 at session 5). Denied suicidal ideation and self-harm urges.
Interventions provided: Reviewed activity log from prior week. Behavioral activation: graded task assignment, adding one social activity and one mastery activity for the coming week. Cognitive restructuring targeting "I'm a burden when I ask for help," using evidence-for/against and a behavioral test (asking brother for a ride). Reinforced paced planning over mood-dependent scheduling.
Response & progress toward goal: Completed 4 of 5 scheduled activities this week; reported the hike "actually felt good for once." Engaged actively in restructuring work and generated alternative thoughts with minimal prompting. Progress consistent with Goal 2 of the treatment plan (increase engagement in valued activities to 5 per week). Symptoms consistent with MDD, improving. Risk: denies ideation; no risk indicators observed; continue routine monitoring.
Plan / next steps: Continue weekly behavioral activation with cognitive work. Homework: activity schedule with one social and one mastery activity, complete the behavioral test with brother. Re-administer PHQ-9 at session 10; review treatment plan goals at session 12. Next appointment 07/16/2026.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsA psychotherapy progress note is part of the designated record set: clients can request it, payers can audit it, and other providers may rely on it. Keep private reflections and hypothesis-level process material out of it; that content belongs in separately maintained psychotherapy notes with their own authorization rules. In substance-use settings, note that the same progress note can also become a 42 CFR Part 2 record when created by a Part 2 program, which changes disclosure rules without changing what good clinical content looks like.
For insurance work, three things carry the audit weight. First, treatment-plan linkage: Medicare's outpatient psychiatric criteria expect an individualized written treatment plan stating the type, amount, frequency, and duration of services, with diagnoses and expected goals. Second, authentication: CMS documentation guidance lists unsigned, undated, or insufficiently detailed progress notes among the failures that trigger denials. Third, time support: the note must document psychotherapy time sufficiently to support the billed code; missing time was a named error in OIG's national psychotherapy audit.
On retention, separate the myth from the rules: HIPAA does not set a retention period for patient charts. HHS says state law generally governs, while Medicare separately requires seven years for covered ordering, certifying, and referral documentation. Ontario and Australia set their own floors; see the table below.
The federal record is unusually specific about how psychotherapy documentation fails. In Medicare's 2024 reporting-period data for outpatient psychiatric services, 16.1% of payments were improper, a projected $254.5 million, and insufficient documentation drove 78.3% of it. A national OIG audit estimated $580 million in improper psychotherapy payments, and a provider-level OIG audit found 111 of 120 sampled psychotherapy claims noncompliant. The BastionGPT Clinical Advisory Board sees the same patterns most often in progress note reviews:
| Aspect | United States | Canada | Australia |
|---|---|---|---|
| Status | Content regulated, structure convention: HIPAA sets the privacy split (progress note vs psychotherapy notes); payers set documentation-support rules | College standards make record-keeping enforceable (Ontario: CRPO for psychotherapists, CPBAO for psychologists); failure to keep proper records is professional misconduct | Psychology Board Code of Conduct (from 1 Dec 2025) plus Ahpra record expectations govern record quality |
| Terminology | Progress note, therapy note, session note | Clinical record, session note | Case note, session note |
| What changes | Treatment-plan linkage, signatures, and time support for billed codes | Ontario: documents with conclusions or diagnoses authored by a supervisee need both signatures | Better Access: no standard referral form, but a written report to the referrer after each course of treatment |
| Retention | No HIPAA chart rule; state law governs; Medicare requires 7 years for covered ordering and referral documentation | Ontario: at least 10 years from last interaction, or from the client's 18th birthday | 7 years since last entry; until age 25 for clients under 18 (Psychology Board Code) |
The clinical core travels across all three countries. What changes is the regulatory layer: privacy categories and payer linkage in the US, college-enforced record standards in Canada, and program-cycle reporting in Australia.
BastionGPT is specifically trained, tuned, and clinically tested on psychotherapy progress notes.
See how clinicians use it day to day on the AI therapy notes page.
Many BastionGPT users report saving more than 90 minutes per day on documentation.
HIPAA-compliant with a signed BAA on every plan. Your data is never used to train models. BastionGPT drafts, you review and sign.
No. The progress note is the shared treatment record. HIPAA's "psychotherapy notes" are a narrow category of private process notes kept separate from the chart, and the legal definition excludes session times, modality and frequency, diagnosis, functional status, treatment plan, symptoms, prognosis, and progress, exactly the content of a progress note.
No. The label does not control the legal status; the content and separate maintenance do. If the note contains diagnosis summaries, treatment-plan content, session timing, or progress to date, it belongs to the ordinary record and is treated that way for access and disclosure, no matter what it is called.
No payer in the sources we reviewed mandates a note structure. What Medicare's outpatient psychiatric criteria expect is content: linkage to an individualized treatment plan with goals, documentation sufficient to support the billed service and time, and signed, dated entries. SOAP, DAP, BIRP, and narrative notes can all carry that content; see the SOAP note template for the most payer-familiar structure.
Most run 100 to 350 words and take 10 to 20 minutes by hand (our clinical team's estimate; no published national benchmark exists). Long enough to name the interventions, the response, the risk status, and the plan; short enough to finish in the minutes after session.
Document time well enough to support the billed code. Missing psychotherapy time is a named cause of improper payment in OIG's national audit, and some Medicare contractors expect start/stop or total time explicitly. We did not find one universal national clock-time wording across all settings, which is why the question persists on coding forums; recording start and stop times is the simplest way to be safe under any contractor.
HIPAA does not set a retention period for patient charts; state law generally governs, and Medicare separately requires 7 years for covered ordering and referral documentation. Ontario's CRPO expects at least 10 years from the last interaction (or from the client's 18th birthday), and Australia's Psychology Board code sets 7 years since last entry, or until age 25 for minors.
The clinician responsible for the service, signed and dated, with credentials. CMS lists unsigned and undated notes among documentation failures, and pasted images of signatures have been flagged in OIG audits. In Ontario, psychologist-board rules add a co-sign duty: documents containing conclusions or diagnoses authored by a supervisee must be signed by both the supervisee and the supervising registrant.
Two things clinicians often miss: there is no standard referral form (a signed, dated letter with the specified content is acceptable), and after each course of treatment the allied mental health professional must send the referrer a written report covering assessments, treatments provided, and recommendations for future management. Your session notes are what that report gets built from.
Yes. Paste a transcript, dictate, or give it bullets, and it produces a structured draft in SOAP, DAP, BIRP, or narrative form for your review. It can also convert notes you already have between structures. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
The compliance claims on this page trace to these authorities, last verified July 2026:
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.