Mental health progress notes refer to notes that psychologists, therapists, clinical counselors, psychiatrists, and other practitioners create at each session about the patient’s clinical status. When maintaining mental health records, clinicians need to consider patient needs, legal requirements, ethical standards, and other factors.These notes include important issues or concerns associated with the patient’s treatment over the course of care. Maintaining accurate psychological records allows providers to monitor their work and promotes continuity of care. Psychiatry transcription services play a key role in helping mental health specialists ensure accurate and timely record keeping. Mental health progress notes are important to provide evidence that competent care was provided, demonstrate medical necessity and more. Many practices follow the S.O.A.P. format (Subjective, Objective, Assessment and Plan).
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