Progress Note Cheat Sheet Patient Prompts 1. Patient reported - Feeling - Experiencing - struggles with - Managing - Overcoming - anxiety surrounding - difficulty with - negative feelings surrounding - issues with 2. Patient explored - Thoughts and feelings about - Past experiences related to - Connections between - Barriers to - Personal beliefs regarding - Triggers - core beliefs - cognitive biases 3. Patient expressed - Concerns about - Satisfaction with - Confusion regarding - Hopes for - Fears about - difficulty with - resistance 4. Patient demonstrated - Progress in - Difficulty with - Mastery of - Resistance to - Improvement in 1 5. Patient identified - Goals for - Triggers of - Patterns in - Strengths of - Coping mechanisms for - attachment style of - struggles with - past experiences with - root of - a connection between - relationships with 6. Therapist guided Patient through - Cognitive restructuring - Relaxation exercises - Exposure exercises - Mindfulness techniques - Problem-solving strategies - grounding techniques - reframing negative thoughts - thought defusion - creating a - identifying goals - forming a plan for - 54321 grounding exercise - 478 breathing exercise 7. Encouraged Patient to - Practice self-compassion - Set realistic goals - Establish healthy boundaries - Seek social support - Prioritize self-care - practice positive self-talk - utilize thought stopping techniques - utilize skills of - communicate with - build a routine 2 8. Provided psychoeducation about - Cognitive distortions - Stress management - Communication styles - Emotional regulation - The impact of trauma - the panic cycle - depressive episodes - manic episodes - affective disorders - addiction - parenting styles - window of tolerance - mindfulness - trauma responses - stages of grief 9. Assisted Patient in developing - A safety plan - Coping strategies - A relapse prevention plan - A daily routine - A mental health maintenance plan - Healthy habits - a plan for - alternative statements - self-care plan - DEAR MAN script for healthy communication - a discharge plan - a treatment plan - goals for treatment - personal goals - professional goals 10. Supported Patient in - Processing grief and loss - Addressing relationship issues - Navigating life transitions - Building self-esteem - Managing symptoms - identifying core beliefs - reframing negative self-talk - creating a trauma narrative - processing emotions related to 3 11. Facilitated discussion on - Personal values - Family dynamics - Cultural considerations - Conflict resolution - Interpersonal effectiveness - mindfulness - cycle of avoidance - the panic cycle - anxiety - the depression cycle - coping strategies - behavioral activation 12. Challenged Patient to - Confront negative beliefs - Break unhelpful patterns - Explore alternative perspectives - Take risks in personal growth - Examine cognitive biases - Identify cognitive distortions - Reframe negative thinking - Begin journaling - Start taking walks - Gamify habits - Maintain personal hygiene / sleep hygiene - Prioritize themself - break cycle of 13. Patient verbalized - Progress made since last session - Feelings of overwhelm - Symptoms experienced - Instances of success - Difficulties faced - Struggles with - hopelessness 14. Patient practiced - Mindfulness techniques - Assertiveness skills - Relaxation strategies - Social skills - Cognitive reframing - Breathing techniques - Grounding exercises 4 15. Patient reflected on - Past successes - Personal growth - Challenges overcome - Unhelpful thought patterns - Impact of past events 16. Patient connected - Current symptoms to past experiences - Emotions to specific situations - Behavior patterns to underlying beliefs - Physical sensations to emotional states - Relationship dynamics to attachment styles 17. Patient acknowledged - Areas for improvement - Progress towards goals - Importance of self-care - Personal responsibility in treatment - Benefits of therapy - sense of grandiosity - discrepancy between 18. Patient shared - Personal stories - Emotional experiences - Coping strategies - Concerns about treatment - Support system - trauma narrative 19. Reviewed with Patient - Treatment goals - Progress notes - Homework assignments - Therapeutic interventions - Session topics - treatment plan - discrepancies - importance of 5 20. Explored with Patient - Ambivalence towards change - Feelings of shame and guilt - Impact of stigma - Frustration with progress - Fear of failure - resistance to change - discrepancy between 21. Collaborated with Patient on - Goal setting - Treatment planning - Identifying resources - Enhancing motivation - Strengthening support network 22. Patient disclosed - Traumatic experiences - Family conflicts - Substance use history - Major life stressors - Relationship dynamics 23. Patient addressed - Unresolved feelings - Patterns of avoidance - Maladaptive coping strategies - Barriers to progress - Emotional triggers 24. Patient examined - Irrational beliefs - Self-defeating behaviors - Impact of past traumas - Long-standing fears - Unmet needs 25. Patient articulated - Personal values - Emotional vulnerabilities - Motivations for change - Internal conflicts - Factors contributing to symptoms 6 26. Patient gained insight into - Unconscious processes - Emotional patterns - Origins of symptoms - Interpersonal dynamics - Cognitive distortions 27. Patient displayed - Resilience - Perseverance - Emotional vulnerability - Defensiveness - Self-awareness 28. Patient engaged in - Role-playing exercises - Behavioral experiments - Guided imagery - Journaling activities - Creative expression 29. Patient processed - Emotional reactions - Cognitive dissonance - Relationship patterns - Intrusive thoughts - Grief and loss 30. Patient brainstormed - Problem-solving approaches - Ways to increase support - Potential obstacles - Strategies for self-care - New coping skills 31. Patient formulated - A vision for the future - Personal goals and aspirations - Steps to achieve desired outcomes - Plans for maintaining progress - A timeline for change 7 32. Discussed with Patient - Importance of consistency in attendance - Benefits of medication adherence - Role of self-compassion in recovery - Strategies for crisis management - Impact of sleep and nutrition on mental health 33. Empowered Patient to - Advocate for their needs - Make informed decisions - Set healthy boundaries - Develop self-efficacy - Take ownership of their healing process 34. Reinforced Patient's - Efforts in therapy - Progress made - Positive coping strategies - Achievements and successes - Personal strengths 35. Patient discussed - Relationship dynamics - Communication challenges - Trust issues - Intimacy concerns - Conflict resolution strategies 36. Patient participated in - Group therapy sessions - Family therapy sessions - Couples therapy sessions - Psychoeducational workshops - Support groups 37. Patient evaluated - Treatment effectiveness - Progress towards goals - Satisfaction with therapeutic relationship - Level of engagement in therapy - Barriers to treatment success 8 38. Patient increased - Emotional awareness - Coping skills repertoire - Social support network - Self-confidence - Level of assertiveness 39. Patient decreased - Symptoms of anxiety - Symptoms of depression - Maladaptive behaviors - Negative thought patterns - Level of distress 40. Patient cultivated - A growth mindset - Self-compassion - Emotional intelligence - Mindfulness practices - Gratitude and appreciation 41. Patient reported on - Homework completion - Use of coping strategies - Successes and challenges - Personal insights - Changes in symptoms 42. Patient received feedback from - Therapist - Group members - Family members - Friends - Other support systems 43. Patient implemented - New communication techniques - Healthy boundaries - Mindfulness practices - Coping strategies learned in session - Changes in daily routine 9 44. Patient attended to - Physical health - Mental health - Emotional well-being - Social connections - Spiritual needs 45. Patient recognized - Personal achievements - Growth in self-awareness - Shifts in thought patterns - Changes in behavior - Development of coping skills 46. Patient explored with therapist - Termination of therapy - Transition to a lower level of care - Referrals to additional resources - Ongoing support options - Future therapeutic goals 47. Patient committed to - Continuation of self-care practices - Ongoing personal growth - Maintaining gains made in therapy - Utilizing support systems - Engaging in relapse prevention strategies 48. Patient expressed gratitude for - Therapeutic support - Personal growth experienced - Increased self-awareness - New coping skills - Improved relationships 49. Patient demonstrated willingness to - Take responsibility for their actions - Continue working on personal growth - Address unresolved issues - Engage in ongoing therapeutic interventions - Apply learned skills to daily life 10 50. Patient and therapist reviewed - Overall progress made in therapy - Accomplishments and areas for continued growth - Therapeutic milestones reached - Strategies for maintaining gains - Plan for ongoing support and resources 51. Patient reassessed - Personal assumptions - Existing coping strategies - Self-perceptions and identity - The influence of past traumas 52. Patient investigated - Interactions between thoughts, feelings, and behaviors - New therapeutic techniques - Underlying causes of stress and anxiety - Potential pathways for personal growth 53. Patient embraced - The process of change - Acceptance of self and others - Positive shifts in mindset - The therapeutic journey as a lifelong process 54. Patient evaluated - Impact of therapy on daily life - Progress towards self-acceptance - Effectiveness of new skills outside of therapy - Changes in personal relationships 55. Patient navigated - Difficult emotional experiences - Transition periods - Conflict within relationships - Stress management techniques 56. Patient adapted - To new situations and environments - Strategies to manage unexpected stressors - New techniques to improve mood and cognition - Learned skills to fit personal needs 11 57. Patient demonstrated capacity for - Emotional growth - Self-reflection - Taking personal responsibility - Empathy towards others' experiences 58. Patient showed willingness to - Accept feedback - Tackle challenging emotions - Engage in difficult conversations - Experiment with new behaviors 59. Patient established - Trust within the therapeutic relationship - A healthier work-life balance - Regular self-care routines - A network of supportive relationships 60. Patient appreciated - Personal growth and development - The importance of self-reflection - The value of therapeutic process - Small victories and progress. 61. Patient broadened - Understanding of personal emotional landscape - Awareness of interpersonal dynamics - Perspective on past events - Ability to empathize with others 62. Patient reinforced - Healthy behavior patterns - Self-care routines - Boundaries within relationships - Commitment to personal growth 63. Patient redefined - Personal values and beliefs - Self-concept and identity - Goals and aspirations - Relationships with self and others 64. Patient strengthened - Ability to manage distress - Confidence in decision-making - Strategies to maintain mental health - Skills for assertive communication 12 65. Patient demonstrated resilience in - Handling setbacks - Facing difficult emotions - Overcoming personal challenges - Pursuing therapeutic goals despite obstacles 66. Patient confronted - Denial or avoidance tactics - Uncomfortable truths - Impact of personal actions on others - Deep-seated fears or insecurities - safety behaviors - core beliefs 67. Patient and therapist established - A treatment plan for future sessions - A stronger therapeutic alliance - A mutual understanding of therapeutic goals - A framework for evaluating progress - a behavioral agreement 68. Patient displayed understanding of - The therapeutic process - The influence of past traumas on current behaviors - The role of thoughts in emotional reactions - The benefits and challenges of change 69. Patient worked on - Enhancing emotional intelligence - Improving problem-solving skills - Refining coping strategies - Building self-esteem and self-efficacy 70. Patient continued to - Practice learned skills outside of sessions - Make strides in personal growth - Show commitment to therapy - Apply feedback in daily life. 13 Therapist prompts 1. Therapist explored client's - Early childhood experiences - Attachment styles - Core beliefs and schemas - Trauma history - Cultural influences - Preconceived notions of therapy - Family of origin - Parenting Style - sense of self 2. Therapist introduced - Cognitive-behavioral techniques - Solution-focused approaches - Psychoanalytic concepts - Acceptance Commitment Therapy - Dialectical Behavioral Therapy - Mind-body interventions - Narrative therapy techniques - Yoga Nidra/Body Awareness - Mindfulness Meditation - the concept of Wise Mind - Internal Family Systems 3. Therapist assessed client's - Social support network - Level of self-care - Coping strategies outside of therapy - Engagement in meaningful activities - Use of leisure and recreation - Risk 4. Therapist supported client in - Identifying and expressing emotions - Building emotional resilience - Enhancing self-compassion - Developing assertiveness skills - Practicing empathy and active listening 14 5. Therapist assisted client in - Identifying and challenging cognitive distortions - Reframing negative thinking patterns - Cultivating self-acceptance and self-esteem - Exploring identity and self-discovery - Developing self-identity outside of roles 6. Therapist explored with client - Intersections of mental health and physical health - Lifestyle factors impacting mental well-being - Impact of sleep and nutrition on mood - Benefits of exercise and physical activity - Coping with chronic illness or pain 7. Therapist collaborated with other professionals - Psychiatrists or medical doctors - Psychologists or neuropsychologists - Occupational therapists or physical therapists - Social workers or case managers - School counselors or teachers 8. Therapist discussed with client - Signs of progress and growth - Moments of resilience and strength - Insights gained from therapy - Therapeutic breakthroughs - Challenges and setbacks - discrepancy between actions/behavior and values - discrepancy between actions/behavior and goals 9. Therapist guided client in - Setting boundaries with others - Exploring personal values and beliefs - Building effective communication skills - Developing conflict resolution strategies - Enhancing decision-making abilities 10. Therapist assessed client's - Level of motivation for change - Willingness to engage in homework assignments - Openness to feedback and suggestions - Readiness to explore deeper issues - Capacity for self-reflection - risk 15 11. Therapist encouraged client to - Practice self-compassion and self-forgiveness - Challenge perfectionism and unrealistic expectations - Embrace vulnerability and authenticity - Engage in self-exploration and self-expression - Foster a sense of purpose and meaning 12. Therapist discussed the impact of - Family of origin dynamics - Cultural and societal influences - Childhood attachment and parenting styles - Environmental stressors and social inequalities - Interpersonal relationships on mental health - thoughts on feelings - feelings on actions/behaviors - negative self/talk on self-esteem 13. Therapist explored client's - Ambivalence towards change - Fear of judgment or rejection - Resistance to vulnerability - Tendency to self-sabotage - Internalized shame or guilt 14. Therapist facilitated client's - Expression of grief and loss - Processing of traumatic experiences - Healing from past hurts and betrayals - Rebuilding trust in relationships - Coping with existential or spiritual concerns 15. Therapist provided education on - Emotional regulation and distress tolerance - Boundaries in relationships and self-care - Developmental stages and transitions - Attachment styles and relationship dynamics - The impact of adverse childhood experiences (ACEs) 16. Therapist assisted client in - Identifying and modifying maladaptive behaviors - Developing problem-solving and decision-making skills - Building resilience and stress management techniques - Enhancing self-awareness and mindfulness practices - Fostering a sense of empowerment and agency 16 17. Therapist explored client's - Internalized beliefs about mental health - Experiences of stigma and discrimination - Coping with societal expectations and pressures - Cultural factors influencing help-seeking behaviors - Advocacy for mental health rights and awareness 18. Therapist reflected on - Therapeutic interventions and their effectiveness - Personal biases and countertransference - Multicultural competence and cultural humility - Ongoing professional development and self-care - Ethical considerations in therapy 19. Therapist discussed with client - Termination or completion of therapy - Gradual reduction of session frequency - Strategies for maintaining progress independently - Plans for ongoing support and resources post-therapy - Availability of follow-up or check-in sessions - importance of medication adherence 20. Therapist and client reviewed - Therapeutic goals and objectives - Progress towards treatment outcomes - Changes in symptom severity or frequency - Integration of therapeutic insights into daily life - Overall satisfaction with the therapy process 21. Therapist encouraged client to - Celebrate small victories and milestones - Reflect on personal growth and progress - Express gratitude for supportive individuals - Acknowledge strengths and positive qualities - Cultivate a positive and growth-oriented mindset 22. Therapist discussed client's - Use of therapeutic tools and resources - Engagement in self-help materials or books - Integration of therapy into daily routines - Attendance and punctuality in sessions - Consistency in completing assigned tasks 17 23. Therapist explored client's - Fears of dependency or abandonment - Desire for independence and autonomy - Attachment needs and attachment styles - Trust in the therapeutic relationship - Transference and countertransference dynamics 24. Therapist encouraged client to explore - Creative outlets for self-expression - Journaling or expressive writing exercises - Art, music, or dance therapy activities - Role-playing or visualization techniques - Imagery or metaphor exploration 25. Therapist provided feedback on - Strengths observed in the therapeutic process - Areas for continued growth and exploration - Progress towards treatment goals - Insights and awareness gained by the therapist - Strategies for overcoming challenges in therapy 26. Therapist discussed the impact of - Media consumption on mental health - Technology use and screen time habits - Social media and online communities - News and current events on emotional well-being - Balancing online and offline relationships 27. Therapist explored client's - Relationship with self and self-esteem - Sense of identity and self-concept - Self-criticism and self-judgment - Body image and self-acceptance - Internal conflicts and self-discrepancies 28. Therapist facilitated client's exploration of - Meaning and purpose in life - Existential questions and concerns - Spirituality and faith-based beliefs - Transcendence and connection to something larger - Values and guiding principles 18 29. Therapist discussed with client - Strategies for managing treatment resistance - Addressing therapeutic ruptures and repairs - Exploring and reframing negative therapeutic experiences - Building trust and rapport in the therapeutic relationship - Collaborative decision-making in the therapy process 30. Therapist acknowledged client's - Efforts in therapy outside of session - Willingness to explore difficult emotions - Vulnerability and openness in sharing personal experiences - Dedication to personal growth and self-improvement - Commitment to the therapy process and positive change 31. Therapist explored client's experience of - Transitions and life changes - Loss and grief processes - Identity crises and self-discovery - Career or educational challenges - Aging and existential concerns 32. Therapist addressed client's - Social anxiety and interpersonal difficulties - Building and maintaining healthy relationships - Dating and romantic relationship concerns - Parenting and family dynamics - Workplace or professional relationship challenges 33. Therapist discussed with client - Impact of childhood experiences on current relationships - Attachment style and relationship patterns - Intimacy and vulnerability in relationships - Conflict resolution and communication skills - Building and maintaining healthy boundaries 34. Therapist explored client's - Dreams and unconscious processes - Symbols and metaphorical language - Fantasies and aspirations - Intrusive thoughts or obsessions - Nightmares or sleep disturbances 19 35. Therapist encouraged client to - Seek community resources and support groups - Engage in volunteer work or altruistic activities - Advocate for mental health awareness and destigmatization - Pursue hobbies or interests outside of therapy - Engage in activities that bring joy and fulfillment 36. Therapist discussed client's - Resistance to vulnerability and emotional intimacy - Fear of rejection or abandonment in relationships - Attachment-related fears and insecurities - Trust-building exercises and strategies - Healing from past relationship traumas 37. Therapist assessed client's - Perception of progress and treatment effectiveness - Satisfaction with therapy and therapeutic relationship - Barriers to engagement in therapy or treatment adherence - Impact of therapy on overall well-being and quality of life - Client's goals for future personal growth and development - risk 38. Therapist discussed the importance of - Self-advocacy and self-empowerment - Resilience and bouncing back from setbacks - Flexibility and adaptability in the face of change - Embracing uncertainty and navigating ambiguity - Embracing the process of growth and embracing challenges - realistic goal setting - positive self talk - sticking to a routine - assertive communication 39. Therapist explored client's - Strengths-based perspective on personal growth - Resourcefulness and problem-solving skills - Coping skills and resilience-building strategies - Personal achievements and milestones - Positive changes in thought patterns and behaviors 40. Therapist addressed the impact of - Trauma on client's mental health and well-being - Triggers and flashbacks related to trauma - Coping with post-traumatic stress symptoms - Healing and recovery from trauma-related experiences - Building a sense of safety and trust in the present 20 41. Therapist discussed with client - The therapeutic process and potential challenges - Collaborative decision-making in treatment planning - Integration of therapy goals with personal values - Flexibility in adapting treatment approaches - Reinforcement of progress and growth in therapy 42. Therapist encouraged client to explore - Supportive and nurturing relationships - Positive role models and mentors - Peer support and group therapy opportunities - Professional networks and communities of practice - Online or virtual support platforms 43. Therapist discussed the impact of - Multicultural factors on mental health experiences - Societal and systemic influences on well-being - Intersectionality and the client's unique identity - Cultural competence and inclusivity in therapy - Addressing microaggressions and cultural insensitivity 44. Therapist explored client's - Body awareness and somatic experiences - The mind-body connection in mental health - Breathing techniques and relaxation exercises - Coping with stress and managing anxiety symptoms - Mindfulness and grounding practices 45. Therapist discussed client's - Rumination and overthinking patterns - Catastrophizing or cognitive distortions - Resilience-building and positive self-talk - Challenging self-limiting beliefs and assumptions - Cultivating a growth mindset and self-compassion 46. Therapist addressed client's - Coping with life transitions and adjustments - Building resilience in times of change or uncertainty - Supportive strategies during periods of stress - Balancing competing priorities and responsibilities - Navigating challenges and setbacks with flexibility 21 47. Therapist discussed with client - Therapeutic homework assignments and their purpose - Application of therapy insights to real-life situations - Reviewing progress on specific therapy goals - Reinforcing positive changes and adaptive behaviors - Exploring challenges or barriers in completing assignments 48. Therapist explored client's - Connection between thoughts, emotions, and behaviors - Recognizing cognitive patterns and automatic thoughts - Building cognitive flexibility and reframing techniques - Cognitive restructuring and challenging negative beliefs - Enhancing cognitive skills for problem-solving and decision-making 49. Therapist discussed with client - Building self-compassion and self-care practices - Creating a balanced lifestyle and self-care routine - Identifying sources of joy and fulfillment in daily life - Incorporating relaxation and stress reduction techniques - Exploring activities that promote self-nurturing and rejuvenation 50. Therapist and client reviewed - Long-term goals for personal growth and well-being - Therapeutic progress over the course of treatment - Changes in symptoms and overall functioning - Therapeutic insights and key learnings - Future plans for maintaining progress and support 51. Therapist utilized active listening to help Patient - Feel heard and understood - Express thoughts and feelings - Gain insight into their experiences 52. Therapist employed cognitive-behavioral techniques to - Identify and challenge irrational thoughts - Replace negative thought patterns with healthier alternatives - Develop coping strategies for managing emotions and behaviors 53. Therapist used motivational interviewing to - Enhance Patient's motivation for change - Explore ambivalence and resistance - Support the development of self-efficacy 54. Therapist applied mindfulness-based interventions to - Improve Patient's present-moment awareness - Develop non-judgmental self-observation - Reduce stress and emotional reactivity 22 55. Therapist implemented psychodynamic approaches to - Explore unconscious processes and conflicts - Examine the impact of early experiences on current functioning - Foster insight into interpersonal dynamics 56. Therapist utilized exposure therapy techniques to - Gradually desensitize Patient to feared stimuli - Develop mastery over anxiety-provoking situations - Reduce avoidance behaviors and increase confidence 57. Therapist employed dialectical behavior therapy (DBT) skills training to - Teach emotion regulation strategies - Enhance interpersonal effectiveness - Develop distress tolerance skills - Promote mindfulness practices 58. Therapist used solution-focused therapy techniques to - Help Patient identify and build upon personal strengths - Focus on solutions and desired outcomes - Foster resilience and optimism 59. Therapist implemented family systems interventions to - Explore family dynamics and patterns - Promote communication and understanding among family members - Address conflicts and facilitate resolution 60. Therapist utilized psychoeducation to - Inform Patient about mental health conditions and treatment options - Provide knowledge about coping strategies and self-care practices - Empower Patient to make informed decisions about their care 61. Therapist facilitated group therapy sessions to - Encourage peer support and shared experiences - Promote social learning and skill-building - Foster a sense of belonging and validation 62. Therapist used narrative therapy techniques to - Help Patient explore and reframe personal stories - Identify and challenge dominant narratives - Empower Patient to create new, empowering stories 63. Therapist employed creative arts therapies to - Encourage self-expression and exploration through art, music, or movement - Foster emotional processing and communication - Promote healing and personal growth 23 64. Therapist integrated play therapy techniques for children to - Facilitate emotional expression and exploration in a safe and engaging manner - Encourage communication and understanding of emotions - Develop social and problem-solving skills 65. Therapist implemented relaxation strategies such as - Progressive muscle relaxation - Deep breathing exercises - Guided imagery - Mindfulness meditation - To help Patient reduce stress and anxiety, and improve emotional regulation 24
