Progress notes play an indispensable role in psychotherapy, serving as a written testament to a client's treatment journey, goals, and advancements. They function as a critical communication tool among mental health professionals, ensuring the delivery of consistent and continuous care, contributing to the research and evaluation of treatment modalities. Furthermore, they are integral to securing insurance reimbursements for both in-network coverage and out-of-network provider claims using Superbills. Inadequate management of progress notes can result in substantial challenges, including denied claims, reduced or delayed reimbursements, and risk of audits.

Challenges with Progress Notes

Given these factors, managing progress notes becomes a significant component of administrative tasks for therapists. On average, mental health professionals spend 10-15 minutes of note-taking per session. This commitment poses numerous challenges. Considering that most therapy sessions last 45-50 minutes, therapists often find themselves struggling to balance preparation for the next client, take necessary breaks, and complete progress notes immediately after the session. Consequently, therapists either reduce their caseload (and hence, their income), or defer note-taking to evenings or weekends, thereby impacting the quality of notes and affecting their work-life balance. With the average mental health professional accepting 3-5 clients per day, the time spent on notes amounts to approximately one hour per day per professional. Moreover, creating these notes is mentally taxing and contributes to therapist burnout.

Solution to the Problem

The CopingCard Provider Platform has recently introduced a feature that addresses the issue of time-consuming progress note-taking, reducing the process to just 1-2 minutes. This efficiency improvement enables therapists to create notes immediately following a session, positively impacting work-life balance, reducing mental fatigue, and providing an opportunity to increase revenue by comfortably expanding caseload and income. This impressive result is achieved through a combination of collecting data, minimal therapist input, and AI.

Example

To demonstrate, let's consider how the AI-assisted Progress Notes generation works using the common SOAP format, and we will later explore the same result in different formats. To provide context, imagine a client with Social Anxiety, treated with Cognitive Behavioral Therapy (CBT). The interventions used include the ABC Model, Downward arrow, Vicious Cycle identification, and Body Scan psychoeducation technique.

Example of generating a Progress Note when the CopingCard platform has been used during the session

Example of generating a Progress Note when CopingCard is used just for the note generation

Progress Notes Formats

There are several commonly used Progress Notes formats, with SOAP (Subjective, Objective, Assessment, Plan) being the most prevalent. Other popular variants include BIRP (Behavior, Intervention, Response, Plan) and DAP (Data, Assessment, Plan). Additional variants are GIRP (Goal, Intervention, Response, Plan) and SIRP (Situation, Intervention, Response, Progress).

Our platform supports AI-assisted notes generation in all the aforementioned formats, allowing each practice to use the format they are most comfortable with.

Details on Formats

Let's explore how the resulting progress note generated with our platform would look in each of these formats using the earlier provided context.

SOAP

Subjective: This section captures the client's problems and symptoms in their own words. For instance, a client might express, "I've been feeling very anxious lately."

Objective: This encompasses the healthcare provider's observations, such as the client's behavior or appearance. Any measurable, observable data like vital signs, test results, or physical exam findings are also included here.

Assessment: This is the provider's opportunity to draw conclusions based on the Subjective and Objective components of the SOAP note. This could be a diagnosis, a change in diagnosis, or a list of possible diagnoses.

Plan: This section documents the proposed management of the client. It could include ordering further tests, therapeutic intervention, patient education, or follow-up instructions.

Generated SOAP Note:

Subjective
The client appeared poorly groomed and was resistant during the session. The client's mood was predominantly anxious, and his affect was flat. He showed mild difficulty concentrating and his speech was rapid and disorganized. His primary thought was 'Everyone is judging me, I do not belong here', especially in social situations such as the 'Pitch event'. This thought was associated with strong feelings of loneliness (66), hopelessness (69) and anxiety (78). The client also reported physical symptoms such as dizziness, weakness, change in heart rate, and sweaty hands. The client was diagnosed with F40.11, a social phobia, generalized disorder.

Objective
During today's session, we used several Cognitive Behavioral Therapy techniques to help the client understand his thought patterns and reactions.
In the ABC Model technique, we investigated the antecedent (Pitch event), the client's beliefs ('Everyone is judging me, I do not belong here') and the consequent emotions of loneliness, hopelessness, and anxiety along with their physical manifestations.
The Downward Arrow technique was used to identify the automatic thought ('At a pitch event, I felt like everyone was judging me and I didn't belong there'). This was linked with an underlying assumption ('I'm not interesting or likable') and a core belief ('I'm a failure and nobody will ever like me').
To address the vicious cycle of anxiety, the 'Public Speaking (Social) Anxiety Cycle' was recognized and documented. This cycle includes Perception of the pitch event as dangerous, Anxiety reaction (symptoms: dizziness, weakness, sweating, heart racing), Avoidance (I did not pitch and left early), and a Persistent perception of public speaking as dangerous.

Assessment
Overall, the client's psychological state appears to be deteriorating, as indicated by his difficulty concentrating, disorganized thought process, and heightened anxiety. His belief that he is unlikeable and his fear of public speaking are contributing to his persistent social anxiety.

Plan
Continue to use Cognitive Behavioral Therapy techniques in the following sessions to help the client understand and challenge his automatic negative thoughts and beliefs about himself. Work on developing more balanced and realistic thought patterns and build confidence in social settings. Encourage client to set small, achievable goals to gradually expose himself to public speaking situations, to manage his social anxiety effectively. Monitor client's progress regularly.

BIRP

BIRP is another widely used format for organizing notes, particularly in mental health and counseling settings. BIRP stands for:

Behavior: This section involves documenting the client's behaviors during the session.

Intervention: This part is where the therapist documents the techniques or strategies they used during the session.

Response: This section is for noting the client's response to the interventions applied.

Plan: Finally, just as in SOAP, DAP, and GIRP, the "Plan" section in BIRP notes outlines the next steps.

The BIRP format is useful in maintaining a focus on the client's behaviors and the therapist's interventions, making it easier to track progress and make adjustments as needed.

Generated BIRP Note:

Behavior
The patient presented with clear signs of social phobia during the session, exhibiting signs of anxiety, displaying a poor appearance and a resistant attitude. His speech was rapid and disorganized. He had difficulty in concentration, pointing towards the severity of his anxiety. The patient's mood was anxious and his affect flat. His thought process seemed disorganized, which might be due to the high level of anxiety he was feeling. The patient's condition showed deterioration, with increased anxiety and poor grooming being the most noticeable changes. He was struggling with thoughts of being judged and not belonging when faced with a pitch event, leading to feelings of loneliness, hopelessness, and heightened anxiety. He also reported physical symptoms like dizziness, weakness, increased heart rate, and sweaty hands.

Intervention
The session involved the use of three key therapeutic interventions:
ABC Model technique: We applied the ABC Model to the patient's thought 'Everyone is judging me, I do not belong here' in the context of a pitch event. The emotions involved were loneliness with strength 66, hopelessness with strength 69, and anxiety with strength 78. The physical sensations he experienced were documented as dizziness, weakness, increased heart rate, and sweaty hands.
Downward Arrow technique: This was used to delve deeper into the patient's automatic thought 'At a pitch event, I felt like everyone was judging me and I didn't belong there.' The underlying assumption here was 'I'm not interesting or likable.' This fed into his core belief 'I'm a failure and nobody will ever like me.'
Vicious Cycle (Maintenance Process) technique: We identified a vicious cycle named 'Public Speaking (Social) Anxiety Cycle' which includes the following steps: Perception of the pitch event as dangerous, anxiety reaction symptoms such as dizziness, weakness, sweating, heart racing, avoidance behaviour (in this case, not pitching and leaving early), and maintaining the perception of public speaking as dangerous.

Response
The patient was resistant during the intervention. His pre-existing anxiety seemed to amplify during the session. He had difficulty concentrating throughout the interventions. However, he was able to identify and articulate his feelings of loneliness, hopelessness, and heightened anxiety in relation to his fear of public speaking. He was also able to recognize and understand the vicious cycle of his 'Public Speaking (Social) Anxiety Cycle'.

Plan
The plan moving forward involves continued use of Cognitive Behavioral Therapy techniques to address the patient's social phobia. Building on the recognition of his 'Public Speaking (Social) Anxiety Cycle', we will focus on developing and implementing coping strategies to manage anxiety, reduce avoidance behaviour, and challenge negative core beliefs and assumptions. The patient may benefit from additional therapeutic interventions such as exposure therapy to help him gradually confront and overcome his fear of public speaking. Regular follow-ups via telehealth are recommended to monitor the patient's progress and adjust treatment plans accordingly. Medication consultation may be considered if the patient's condition does not improve.

DAP

DAP is another common format for organizing notes in the medical, mental health, and social work fields. DAP stands for:

Data: This is analogous to the "Subjective" and "Objective" parts of the SOAP format. It includes both what the patient reports about their symptoms or experiences, as well as what the healthcare provider observes directly.

Assessment: Like in the SOAP format, the "Assessment" portion of a DAP note is where the healthcare provider makes their professional evaluation. This could be a diagnosis, a change in diagnosis, or a hypothesis about what could be causing the patient's symptoms or experiences.

Plan: Again, like in SOAP, the "Plan" portion is where the healthcare provider lays out the next steps for addressing the patient's needs. This could be a treatment plan, referrals to other services or providers, a plan for follow-up, or any other next steps.

The DAP note format is designed to be a bit more flexible than the SOAP format. It's often used in fields like mental health and social work where the line between a patient's self-reported experiences and a provider's observations might be more blurred.

Generated DAP Note:

Data
During today's telehealth session from the patient's home, the client presented with a poorly groomed appearance and resistant attitude. His mood was anxious, and his affect seemed flat. His speech was rapid, and he exhibited a disorganized thought process. He also displayed mild difficulty concentrating. The client showed signs of deterioration in the session. His primary diagnosis is F40.11 Social phobia, generalized. The signs of this were clearly observed in the client's expressions of anxiety and loneliness, his disorganized thought process, and the physical sensations he described experiencing.

With the use of the ABC Model technique, we addressed the thought "Everyone is judging me, I do not belong here," which the client associated with the situation "Pitch event." He expressed feelings of loneliness at strength 66, hopelessness at strength 69, and anxiety at strength 78. The client also reported experiencing dizziness, weakness, a change in heartbeat rate, and sweaty hands.
Using the Downward Arrow technique, we explored the automatic thought "At a pitch event, I felt like everyone was judging me and I didn't belong there." This thought was underlined by the assumption that he is not interesting or likeable, with a core belief that he is a failure and nobody will ever like him.
The Vicious Cycle (Maintenance Process) technique aided in identifying a new vicious cycle. Named "Public Speaking (Social) Anxiety Cycle", this cycle consists of the perception of the pitch event as dangerous, the anxiety reaction (symptoms) such as dizziness, weakness, sweating and heart racing, and avoidance behaviours like not pitching and leaving early. This has led to persistent perception of public speaking as a threatening event.

Assessment
The client's flat affect, disorganized thought process, and physical symptoms reflect his high level of anxiety and social phobia. His resistance to the session raises concerns about his willingness to engage in therapeutic interventions. Moreover, his automatic negative thoughts and underlying assumptions reflect a pessimistic view of self, which potentially contributes to his feelings of loneliness and hopelessness. The client's reported avoidance behaviours, such as early departure from pitch events, further reinforce his anxiety and negative thoughts.

Plan
Moving forward, therapy sessions will involve challenging the client's negative thoughts and beliefs using cognitive restructuring techniques. The client will be encouraged to engage in exposure therapy, slowly exposing him to social situations such as public speaking. This approach will help to gradually reduce his anxiety and avoidant behaviours. The aim is to break his existing vicious cycle of anxiety and avoidance. A constant monitoring of his progress in these areas will be done to ensure the effectiveness of the therapeutic interventions. Furthermore, the client will also be provided with coping strategies to manage his physical symptoms caused due to anxiety.

GIRP

GIRP is yet another commonly used format for organizing notes in mental health and social work fields. It stands for:

Goal: This part of the note identifies what the patient and provider hope to achieve in their work together. Goals should be specific, measurable, attainable, relevant, and time-bound (SMART).

Intervention: This section describes the specific methods or techniques the provider used to help the patient work toward their goal.

Response: Here, the provider notes how the patient responded to the intervention.

Plan: Like in the SOAP and DAP formats, the "Plan" portion of a GIRP note outlines the next steps.

The GIRP format is particularly useful for tracking progress over time because it emphasizes the relationship between the provider's interventions, the patient's response, and the overarching treatment goals.

Generated GIRP Note:

Goal
The goal of today's session was to address the patient's generalized social phobia, specifically their acute anxiety related to public speaking events. The intent was to help the patient identify and reframe negative thought patterns and emotional reactions linked to these scenarios.

Intervention
ABC Model: We created a new ABC Model for the patient's thought pattern that suggested "Everyone is judging me, I do not belong here" in the context of a "Pitch event". The associated emotions were high levels of loneliness (66), hopelessness (69), and anxiety (78), paired with physical sensations such as "dizziness", "weakness", "heartbeat rate change", and "sweaty hands". This technique allowed us to map out the connection between thoughts, feelings, behaviors, and physical reactions in specific situations.
Downward Arrow: We applied this technique to peel back layers of thinking and examine the deeper assumptions and beliefs that drive superficial thoughts. For the automatic thought "At a pitch event, I felt like everyone was judging me and I didn't belong there.", we identified the underlying assumption as "I'm not interesting or likable." and the core belief as "I'm a failure and nobody will ever like me".
Vicious Cycle (Maintenance Process): We identified and documented a new vicious cycle entitled "Public Speacking (Social) Anxiety Cycle". This cycle consisted of thoughts, actions, or facts including: "Perception of the pitch event as dangerous", "Anxiety reaction (symptoms): diziness, weakness, sweating, heart racing", "Avoidance - I did not pitch and left early", and "Public speaking (pitching) is still perceived as dangerous".

Response
The patient demonstrated difficulty in participating actively in the session. They appeared poorly groomed, resistant, and spoke rapidly, indicating heightened anxiety. Their expressed thoughts were disorganized. Despite these challenges, they were able to engage with the therapeutic techniques, though the concentration difficulty was evident. Their mood was marked by constant anxiety, and their affect was flat.

Plan
We planned to continue with the cognitive-behavioral interventions in our subsequent sessions. The goal is to help the patient develop more adaptive interpretations of social scenarios and reduce their anxiety. Emphasis will be placed on enhancing the patient's capacity to apply these techniques outside therapy sessions. The significant level of anxiety and worsening of the patient's condition necessitate a reassessment of our therapeutic methods, potentially including a consultation for medication evaluation. Patient was encouraged to practice self-care and relaxation techniques in between sessions.

SIRP

SIRP is another format used in clinical settings for organizing and documenting notes. SIRP stands for:

Situation: This part of the note describes the current situation or context.

Intervention: This section documents the specific methods, techniques, or strategies used by the professional to address the client's situation.

Response: Here, the professional records how the client responded to the intervention.

Plan: As with the other formats (SOAP, DAP, GIRP, BIRP), the "Plan" section in a SIRP note outlines the next steps.

The SIRP format is particularly useful for maintaining a clear focus on the client's current situation, the professional's intervention, the client's response, and the plan for moving forward.

Generated SIRP Note:

Situation
The patient arrived for the session appearing visibly distressed and poorly groomed. His overall demeanor was resistant, with a general air of anxiety evident. Speech patterns were rapid and somewhat disorganized, hinting at a mildly difficult concentration level. A flat affect was observed indicating emotional blunting. Major diagnostic consideration is Primary Diagnosis: F40.11 Social phobia, generalized. The presenting problem was the patient's heightened anxiety about public speaking, particularly in a pitch event scenario where he felt extremely judged and out of place.

Intervention
ABC Model Technique: We created a new ABC Model for the thought 'Everyone is judging me, I do not belong here', in the situation 'Pitch event'. The patient reported experiencing emotions of loneliness with strength 66, hopelessness with strength 69, and anxiety with strength 78. Additionally, he reported physical symptoms such as dizziness, weakness, change in heartbeat rate, and sweaty hands.
Downward Arrow Technique: This method was employed to delve into the patient's automatic thought connected to public speaking. The automatic thought 'At a pitch event, I felt like everyone was judging me and I didn't belong there' was explored. The underlying assumption was 'I'm not interesting or likable', with the core belief being 'I'm a failure and nobody will ever like me’.
Vicious Cycle Technique: A new vicious cycle named 'Public Speaking (Social) Anxiety Cycle' was identified and documented. This cycle included elements like perception of the pitch event as dangerous, anxiety reaction symptoms (dizziness, weakness, sweating, heart racing), avoidance behaviour (early departure from the event), and a reinforcement of the public speaking fear.

Response
The patient proved to be reasonably responsive to the interventions, but his overall resistance was a hurdle in the process. The techniques used aimed to address his social phobia and associated anxiety. It was observed that the ABC Model helped the patient understand how his thought processes, emotions, and physiological responses are intertwined. The Downward Arrow technique shed light on his automatic thought process and core belief, linking his immediate thought with a deeper, more ingrained belief about self-worth. Understanding of the Vicious Cycle was a crucial part of the therapy. The patient was able to identify and visually understand his fear and avoidance behaviour.

Progress
However, despite the therapeutic interventions, marked deterioration in the client's state was noted, suggesting that the anxiety and social phobia symptoms have become more severe. There appears to be persistent negative thought patterns and avoidance behaviour. His resistance to the therapeutic process was a significant challenge. Clients' motivation and commitment for the next session can be of concern due to his heightened anxiety. Given the current situation, ongoing CBT and possibly integrating other therapeutic interventions, or considering referral to a psychiatrist for pharmacological intervention, may be necessary. Session took place via Telehealth in the Patient's home.

Conclusion

Taking Progress Notes immediately after a session with a client is crucial to ensure accuracy. However, the reality for many therapists, with sessions lasting 45-50 minutes, is that there is not enough time between sessions to take a break, prepare for the next client, and complete progress notes, which on average takes 10-15 minutes. This results in lower quality of notes, triggering potential side effects like higher probability of audits, delayed or reduced payouts, denied claims, etc. Additionally, the deferred creation of progress notes often leads to additional workload outside regular hours or during weekends, causing issues with work-life balance, or leading to a reduced caseload, and hence, income.

Our platform offers a solution to these challenges. By requiring minimal information from professionals and leveraging a combination of collected data and generative AI language models, our platform automates the process of transforming minimal input into comprehensive progress notes in a preferred format. This process takes only 1-2 minutes, making it feasible to create notes immediately after a session. This efficiency not only frees up time and reduces mental fatigue, but also allows therapists to regain work-life balance and potentially increase their revenue.

On a broader scale, this solution addresses the increasing shortage of mental health professionals. By reducing the administrative workload of therapists, we enable them to treat more clients and contribute to alleviating the growing mental health crisis. With the CopingCard Provider platform, mental health practice owners can ensure a more efficient, effective, and balanced approach to client care.