Compliant Progress Notes Cheatsheet

As both a medical and legal form, progress notes are essential documentation for mental health care providers. When crafted with care and compliance, they can amplify treatment effectiveness and establish a clear record of clinical decision-making. On the other hand, we know progress notes can be a source of administrative stress, often taking hours to complete—not to mention the lingering awareness of a potential audit.

Putting those worries aside, it’s never been easier to ensure you’re meeting the right requirements. At Alma, we recommend a more comprehensive approach to writing progress notes, based on insights from our thorough review of documentation audits, direct feedback received from our payer partners, and recommendations from coding and documentation specialists.

While no progress notes template guarantees audit approval, the guidelines in this checklist cover everything providers need for streamlined and compliant mental health progress notes, like relevant session details to actionable next steps. When you know your progress notes are in order, you can breathe easier—and continue providing great care.