A brief written record of what happened in a session or contact.
In the context of addiction treatment:
Documents symptoms, interventions, response, and next steps; it’s part of your medical record.
What to know:
-
Notes help keep the whole team on the same page.
-
They may be reviewed by insurers or auditors to confirm care is appropriate.
Example:
A progress note might say: “Client reported 2 cravings this week, used coping skills, remained abstinent, plans to attend 4 meetings.”