Adding progress notes for individual appointments

You can add a progress note for every client appointment. Progress notes are tied to the client’s medical record and are included in records shared with other professionals, insurance companies, and data exports when required.

In this guide, we’ll cover:

• Creating a progress note
• Editing, printing, downloading, or deleting a progress note
• Signing and locking progress notes
• Sharing a progress note with a client for e-signature
• Unlocking a locked progress note

Note: This guide covers the manual creation of progress notes. To use Note Taker for AI driven creation of progress notes, see Understanding Note Taker.

To learn more about progress notes for group appointments, see Adding progress notes for group appointments. To learn about psychotherapy notes, see Adding psychotherapy notes.

Creating a progress note

Tip: You can use the Appointment status report to find appointments missing progress notes. To learn more, see Navigating the Appointment status report.

To create a progress note:

1. Navigate to the client’s Overview page
2. Click the Appointment you want to add a progress note to

Note: This opens the appointment page. For more ways to access it, see Navigating the appointment page. 

3. Select a progress note template from the dropdown menu

Note: The updated appointment page is gradually being released to customers. This page may look slightly different in your account and will be updated shortly.

To add a template to the dropdown, see:

• Adding a pre-built template or Creating a new template and accessing the template builder to add it to your template library
• Managing your template library to add it to available templates to use when you're creating documentation

Note: If you’re on the Starter plan, you can select a Simple Progress Note template or populate the note with a SOAP or DAP template. On the Essential and Plus plans, you can choose from pre-built templates or customized progress note templates.

Next, follow the steps below:

1. Enter your note content in the text fields

To save time while writing:

• Use snippets to insert frequently used text
• Click Load last note to reuse a previous progress note

On the Essential or Plus plan, the arrow next to Load last note lets you choose from the client’s last 25 notes.

Note: On the Starter plan, only the most recent note can be loaded.

5. Click Save when you’re done

Important: Always click Save before leaving the page to avoid losing work.

After a progress note is saved for an appointment, the appointment can't be deleted unless the progress note is deleted. However, all of the appointment's details can still be edited, as long as the progress note hasn't been signed.

If you have an appointment that was updated from Show to another status (i.e. Late Canceled), you'll still be able to write a progress note for the appointment when you click on that appointment from the client's Overview page. 

Every appointment will require a progress note. At this time, there's no way to disable this requirement. However, if the appointment is updated to Canceled, Clinician canceled, or Late Canceled, the notification to create a progress note will be disabled. For more information, see Using practice notifications.

Editing, printing, downloading, or deleting a progress note

Important: Locked notes can’t be edited or deleted. To make changes, see Unlocking a locked progress note.

To edit a progress note:

1. View the unlocked progress note
2. Click Edit

3. Make your changes and click Save

To print, download, or delete a note, click More and choose the option you need.

Important: Deleted notes can’t be recovered.

Signing and locking progress notes

To sign and lock a progress note:

1. View the unlocked progress note
2. Click Sign

3. Review the signature preview and edit Provider Name or Credentials if needed
4. Click Sign and lock

Note: Your name and credentials populate from Settings > Profile > Profile and security and Settings > Profile > Clinical info.

Pre-licensed clinicians can share notes with supervisors. For more information, see Reviewing and signing documentation under supervision.

After a progress note is signed, the associated appointment's time, date, and duration can't be edited, though other details can still be updated for the appointment. If these items need to be edited, the progress note must be unlocked and deleted.

Sharing a progress note with a client for e-signature

After signing and locking a progress note, you can share it with a client for their e-signature. To do this:

1. Open the client’s Overview page
2. Select the appointment with the signed note
3. Click Share

4. Click Continue to Email
5. Review the email and select Continue to Review
6. Click Share & Send Now

After the client or contact signs, both signatures appear on the appointment page.

Note: Only the five most recent progress notes can be shared via the Client Portal. To view and share older notes, you can perform a data export.

Unlocking a locked progress note

Progress notes are important for creating a legal health record of your client encounters, client billing, and measuring client progress. Account Owners and clinicians who have been granted this permission can unlock progress notes to make amendments, corrections, or clarifications.

This feature should be used with care and in a manner that's consistent with HIPAA requirements and professional ethics, which include:

• Being vigilant about maintaining the security and privacy of your SimplePractice account, such as using antivirus software, strong passwords for your accounts and your devices, maintaining a safe environment for storing your records, and taking other necessary precautions
  • Find more information on recommended practices on our Security page
• Making sure you’re always logged in to your own account and never sharing accounts with others, including team members
• Monitoring and auditing your Account Activity on a regular schedule to identify any unusual behavior immediately
  • Any time the Unlock feature is used, a new entry will be logged in your Account Activity
    • Keep in mind that any edits made to the progress note will overwrite the original note
  • For more information, see Account Activity: Tracking changes and information access in your account
• Training your HIPAA workforce, including clinical and administrative staff, in accordance with the Privacy and Security Rules

While this feature is built in a HIPAA-compliant way, you and your team members are ultimately responsible for safeguarding the information in your SimplePractice account.

For more information, see:

• Summary of the HIPAA Security Rule
• Security 101 for Covered Entities
• Electronic Health Records Provider fact sheet
• Fundamentals of the Legal Health Record and Designated Record Set

Important: Progress notes that have been signed by a client can’t be unlocked.

To unlock a locked progress note:

1. Click Unlock at the top of the note
   

Note: If you're not seeing this option, you may need permission to unlock progress notes. To be granted permission for this, see Updating a team member’s roles.

2. Under the Notice of Data Integrity, type the Reason for unlocking in the text field
3. Click Accept & Unlock

You'll see the Unlocked message beneath the progress note.