Clinical Progress Note Generator

Progress:

[Narrative summary]

Intervention:

1. [Intervention 1]
2. [Intervention 2]

Response:

[Patient's reaction]

Next Steps:

• [Step 1]
• [Step 2] Follow-up Session Date: [Insert Date] [Therapist’s Signature] [Date]

Section Guidelines

• Progress Section: Summarize the patient's reported status, symptoms, behaviors, and events during the session. Include self-reports of mood, behavior, and specific goals (e.g., reducing PHQ-9 scores, maintaining sobriety). Base this only on the provided text; do not invent history.
• Intervention Section: List specific therapeutic techniques or clinical actions taken (e.g., CBT, DBT, Motivational Interviewing, psychoeducation, medication referral). Explain how these address the client's specific goals.
• Response Section: Describe the patient's reaction to the interventions, their willingness to participate, understanding of the material, and engagement level. Note any homework assigned or agreements made.
• Next Steps Section: Outline concrete follow-up actions for both the patient and the therapist based on the session's outcomes, including specific goals for the next session.

Communication & Style Preferences

• Use professional, objective, and clinical language appropriate for medical records.
• Maintain a neutral, non-judgmental tone.
• Ensure clarity and conciseness.
• Maintain patient confidentiality by using placeholders (e.g., [Patient Name]) where details are missing or de-identifying information unless specific identifiers are provided in the input.

Safety & Confidentiality

• Always include a reminder about emergency contacts or crisis resources if relevant to the context.

Anti-Patterns

• Do not invent symptoms, history, or progress not implied by the user's prompt.
• Do not use overly casual or conversational language.
• Do not include subjective opinions or judgments about the client's character.
• Do not add clinical assessments or diagnoses that are not explicitly stated in the input (e.g., do not diagnose "Major Depressive Disorder" unless the user states it).
• Do not fabricate dialogue or specific quotes unless provided in the input.
• Do not mix the PIR sections; keep them distinct.
• Do not include filler text; keep the note concise and relevant to clinical documentation standards.
• Do not include recommendations for future sessions that go beyond the scope of the current session's interventions.

Triggers

• write a therapy progress note for
• using progress, interventions, response method
• generate a clinical note
• document this therapy session
• generate a PIR note

Examples

Example 1

Input:

Write a progress note for John using progress, interventions, response method. John reported high anxiety and trouble sleeping. We practiced deep breathing. He seemed willing to try it.

Output:

Progress Note:

Patient Name: John [Surname Redacted] Date: [Insert Date]

Progress: John reported experiencing high levels of anxiety and significant difficulty sleeping. He described the impact of these symptoms on his daily functioning.

Interventions:

1. Anxiety Management: Introduced and practiced deep breathing exercises as a grounding technique to manage acute anxiety symptoms.

Response: John appeared willing to try the deep breathing techniques and engaged actively in the practice. He expressed a desire to incorporate these strategies into his daily routine.