At Ruh, we recognize that documentation is not only a professional obligation but also an Amanah (sacred trust). Writing progress notes with integrity upholds the ethical responsibility we have to our clients and ensures that our records reflect both the clinical and spiritual dimensions of healing. Islamically aligned therapy calls for compassion, accuracy, and a commitment to providing care that honors the dignity and privacy of our clients.
Progress notes are essential for tracking client progress, assessing treatment effectiveness, and ensuring continuity of care. Additionally, maintaining thorough and accurate records is crucial for compliance with insurance requirements, as they provide necessary documentation for reimbursement and audits. Below are key elements to include in your notes, recommended structure, and policies to follow.
Key Components of a Progress Note
Clinically Relevant Client Information
Document significant details from the session that illustrate the clientâs mental health status.
Include thoughts, feelings, and symptoms in the clientâs own words whenever possible (e.g., Client stated, "I feel like I have no energy to do anything.")
Note any risk factors and your clinical response if applicable.
Avoid subjective assumptions; ensure documentation is factual and based on observable or reported information.
Approach note-taking with sincerity and honesty, recognizing the trust clients place in their therapist.
Clinician's Observations and Assessment
Mood/Affect: When providing observations, ensure they are backed up with specific evidence. You may choose to use "AEB" (As Evidenced By) to support your description. E.g., Client appeared anxious, AEB fidgeting, rapid speech, and difficulty maintaining eye contact.
Interventions Used & Response: Describe techniques used and how the client responded (e.g., CBT, grounding exercises, Islamic psycho-spiritual interventions).
Receptivity: Note if the client was engaged, guarded, or if their emotions shifted.
Consistency: Ensure notes reflect prior sessions to track progress or emerging patterns.
Spiritually Integrated Care: If faith-based coping strategies or Islamic principles were incorporated, document how they were received and their impact on the client.
Plan Moving Forward
Outline next steps for therapy, including interventions or topics to revisit.
Justify the need for continued therapy (e.g., ongoing distress, lack of coping mechanisms, unresolved trauma).
If referrals or consultations are necessary, document rationale and next steps.
Align treatment with the clientâs values and faith-based perspectives when applicable.
Recommended Note Structures
SOAP Note Format:
S (Subjective): Clientâs reported experience, thoughts, and feelings.
O (Objective): Therapistâs observations (mood, affect, behaviors).
A (Assessment): Therapistâs clinical impression and progress assessment.
P (Plan): Next steps, interventions, and rationale for continued therapy.
DAP Note Format:
D (Data): Clientâs reported symptoms and therapistâs observations.
A (Assessment): Clinicianâs interpretation of the clientâs progress and mental health status.
P (Plan): Future therapeutic direction and any follow-up actions.
Free Text Format:
A flexible option allowing for a narrative approach while ensuring all key components are addressed.
Best Practices for Writing Progress Notes
Keep notes concise yet clinically relevant (4-8 lines is typically sufficient).
Use professional language: "Therapist exploredâŚ", "Client verbalizedâŚ", "Client reportedâŚ"
Ensure all entries are objective, nonjudgmental, and free of unnecessary details that do not contribute to clinical care.
Avoid abbreviations that are not widely recognized to ensure clarity across providers.
Review notes before submission to ensure accuracy and completeness.
Uphold the Amanah of documentation by ensuring honesty, professionalism, and ethical responsibility.
Submit progress notes within 48 hours to ensure compliance with insurance and documentation standards.
Sign and lock notes in a timely manner to maintain documentation integrity.
If running behind, notify your Clinical Manager or supervisor.
By following these guidelines, therapists can ensure clear, effective documentation that supports client care and aligns with the Islamic values of integrity, sincerity, and accountability that guide Ruhâs approach to therapy.