A progress note is the entry you write after a patient encounter to record what happened and what comes next. It’s the running account of a patient’s care, one note per visit, building into the story of how they’re doing over time. “Progress note” is the umbrella. SOAP, DAP, BIRP, and plain narrative are formats you can write one in. This page covers what goes in a progress note, how to pick a format, two worked examples, and a blank template.
The word trips people up because “progress note” and “SOAP note” get used as if they mean the same thing. They don’t. The note is the document; the format is how you organize it. Once that’s clear, the real question is which format fits which encounter, and that’s mostly about whether the visit has measurable findings to separate from the patient’s own report. We’ll sort that out below.
Key takeaways
- A progress note is one document; SOAP, DAP, BIRP, and narrative are four formats for writing it.
- Pick the format by the encounter: SOAP for visits with exam findings, DAP or BIRP for talk therapy, narrative for short interval updates.
- No payer or law mandates a format. They require content: medical necessity, legible, dated, signed, per 42 CFR 482.24 and CMS guidance.
- Primary-care physicians log a median of 36.2 minutes of EHR time per 30-minute visit, so the note now outlasts the visit it describes.
- An AI scribe drafts the progress note for you in about two minutes; you still read and sign every one.
common progress-note formats: SOAP, DAP, BIRP, narrative
of EHR time logged per 30-minute primary-care visit (JAMA Network Open, 2023)
to review an AI-drafted progress note after the visit ends
What is a progress note, and what does it record?
A progress note documents one encounter and connects it to the ones before and after. That’s the whole job. Someone covering your panel next week opens the chart, reads your last note, and knows what’s going on without calling you. A reviewer pulls the record a year later and sees that the visit happened, what you found, and why you did what you did. The note is the only durable trace of a conversation that’s otherwise gone the moment the patient leaves.
Per StatPearls, the SOAP note, the most common form, is “an essential piece of information about the health status of the patient as well as a communication document between health professionals.” That second half matters. A progress note isn’t a diary. It’s written to be read by other clinicians, by you on a worse day, by a coding team, sometimes by a court. So it carries a fixed core no matter which format you choose:
- What the patient reports today, in their words where it counts.
- What you observe or measure: exam, vitals, scores, results.
- Your clinical read of it: the diagnosis or working impression, the reasoning.
- The plan: medications, tests, referrals, the next visit, what changed.
Federal rules set the floor for how that entry has to look. Under 42 CFR 482.24, medical records must be “accurately written, promptly completed, properly filed and retained, and accessible,” and every entry has to be “dated, timed, and authenticated.” None of that says SOAP. It says the note must be real, complete, and signed by you. The format is your call inside those lines.
What are the common progress note formats?
Four formats cover almost everything you’ll write. They differ in how they slice the same content, not in what counts as a good note.
| Format | Sections | What it’s tuned for |
|---|---|---|
| SOAP | Subjective, Objective, Assessment, Plan | The cross-discipline default. Splits the patient’s report from your measured findings, then your judgment. Fits any visit with an exam. |
| DAP | Data, Assessment, Plan | Folds report and observation into one Data block. Faster for talk therapy, where reported-versus-observed is a blurry line. |
| BIRP | Behavior, Intervention, Response, Plan | Separates what you did from how the client reacted. Common in Medicaid and substance-use work because medical necessity reads off it cleanly. |
| Narrative / interval | No fixed headers; chronological prose | Short updates: an inpatient interval note, a quick follow-up, a phone check. Less structure, faster, easier to leave a gap in. |
SOAP is what most clinicians trained on, and it’s what most AI scribes draft by default. DAP and BIRP are behavioral-health adaptations: DAP collapses a section to write faster, BIRP adds a section to make a billable intervention obvious to a reviewer. Narrative notes are the oldest form and still the right tool for an interval update where four headers would be overkill.
We go deep on the behavioral-health formats in their own guides. The DAP note guide covers Data-Assessment-Plan with a worked therapy example. The BIRP note guide walks through Behavior-Intervention-Response-Plan. And if you write SOAP for therapy specifically, how to write a mental-health SOAP note has a six-point rubric for grading drafts. This page is the level above those: which one to reach for, and why.
Which progress note format should you use?
This is the picker most of this page builds toward. Match the row to your encounter, and if your agency or payer already named a format, that overrides everything below.
| If the encounter is… | Reach for | Because |
|---|---|---|
| A medical visit with an exam, vitals, or labs | SOAP | You have objective findings worth keeping in their own section, separate from what the patient told you. |
| A primary-care or specialty follow-up | SOAP | The four headers map cleanly to how the visit runs, and coders and reviewers expect them. |
| A talk-therapy or counseling session | DAP | The line between reported and observed is blurry in therapy; one Data section reads more naturally than forcing Subjective-versus-Objective. |
| A session where you must show a billable intervention worked | BIRP | The Intervention and Response sections put medical necessity on the page for a payer to read. |
| A short interval update, a phone follow-up, an inpatient daily | Narrative | A quick chronological note beats four mostly-empty headers; just don’t let it drop the plan. |
| A note your employer or Medicaid program specifies | Their format | A contract requirement isn’t a preference. Match the headings they audit against. |
Two honest caveats, because the table makes it look cleaner than practice is. First, plenty of clinicians keep two formats in their head and switch per encounter, a SOAP note for the medication-management half of a visit, a DAP note for the therapy half. That’s normal. Second, the format is the smallest decision here. A SOAP note with a hollow Assessment is worse than a narrative note that actually says what you were thinking. Structure helps; it doesn’t substitute for content.
A worked progress note example in SOAP format
This is the artifact. Below is a complete progress note for a routine primary-care follow-up, written the way a competent scribe should draft it from the visit audio. The case is invented; no real patient. The shape and detail are what you should expect on screen about two minutes after a visit ends.
Encounter: Established adult patient, type 2 diabetes and hypertension, three-month follow-up.
Subjective: Patient reports feeling well overall. Checking blood glucose most mornings, fasting values “usually around 130 to 145.” Taking metformin 1000 mg twice daily and lisinopril 20 mg daily as prescribed, no missed doses this month. Denies polyuria, blurred vision, chest pain, or swelling in the legs. Walking 20 minutes most days, down from the soda he cut out two months ago. One concern: occasional lightheadedness when standing quickly, two or three times a week, resolves in seconds.
Objective: BP 128/78 seated, 122/76 standing. Weight 94 kg, down 2 kg since last visit. Heart regular rate and rhythm, lungs clear, no peripheral edema. Feet examined: intact sensation to monofilament, no ulcers or lesions. Point-of-care A1c 7.1%, down from 7.6% three months ago.
Assessment: Type 2 diabetes, improving glycemic control (A1c 7.6 to 7.1). On track toward the under-7 goal with current regimen and lifestyle changes. Hypertension well controlled on lisinopril. Orthostatic lightheadedness is mild and positional; no orthostatic drop on today’s readings, likely benign, will monitor. No signs of diabetic neuropathy or retinopathy reported.
Plan: Continue metformin 1000 mg twice daily and lisinopril 20 mg daily, no changes. Continue current diet and walking. Recheck A1c in three months. Referred to ophthalmology for annual diabetic eye exam, last one over a year ago. Counseled to stand up slowly and stay hydrated; return sooner if lightheadedness worsens or he has a near-fall. Follow-up in three months.
Read it the way you’d read your own. The Subjective is the patient’s report, including the lightheadedness he volunteered. The Objective is what was measured, the two blood-pressure readings, the A1c, the foot exam, and nothing interpretive. The Assessment is where the thinking lives: the trend, the goal, the read on the lightheadedness. The Plan is specific. Not “continue treatment” but the actual doses held, the actual referral, the actual safety advice. A vague Plan is a Plan you’ll rewrite.
A worked progress note example in narrative format
Same patient class, different format, to show the contrast. A narrative interval note has no headers; it’s chronological prose. It’s faster, and it’s easier to leave a hole in, so the discipline is making sure the plan still lands. This one is an inpatient daily progress note, again invented.
Encounter: Hospital day 3, adult admitted for community-acquired pneumonia.
Day 3 of admission for community-acquired pneumonia. Patient reports the cough is looser and less frequent, no chest pain, appetite returning. Overnight temperature peaked at 37.8 C, down from 38.9 C on admission. This morning afebrile at 36.9 C, oxygen saturation 95% on room air, off supplemental oxygen since yesterday evening. Lungs with improving air entry at the right base, scattered crackles persist but reduced. Tolerating oral intake, IV fluids discontinued. White count trending down, 11.2 from 14.6 on admission. Clinically improving on day 3 of oral antibiotics after transition from IV yesterday. Plan: continue oral amoxicillin-clavulanate to complete a 7-day course, encourage ambulation and incentive spirometry, anticipate discharge tomorrow if afebrile overnight and saturations hold on room air. Discharge planning started with nursing; will arrange primary-care follow-up within one week.
No headers, but every part of a SOAP note is in there, woven into the timeline: what the patient reports, the vitals and exam, the clinical read, the plan. That’s the trick with narrative notes. The structure is invisible, but the content can’t be. Drop the plan and you’ve left the next clinician guessing.
A blank progress note template you can copy
Below is a format-agnostic template. Fill the sections that fit your encounter; for a narrative note, treat the headers as a checklist of things the prose has to cover rather than literal labels.
| Section | What to put here | Skip if |
|---|---|---|
| Identifier / context | Date, visit type, who the patient is in one line, why they’re here today | Never. Every note needs this. |
| Subjective / what’s reported | The patient’s account: symptoms, changes since last visit, adherence, concerns. Quotes where they carry weight. | Nothing reported (rare; usually there’s something). |
| Objective / what’s measured | Vitals, exam findings, scores, lab and imaging results, anything you observed firsthand | A pure phone or message check with no exam, fold it into the narrative. |
| Assessment / your read | Diagnosis or working impression, the trend, your reasoning, risk if relevant | Never. This is the section that justifies the visit. |
| Plan / what’s next | Medications held or changed, tests ordered, referrals, patient instructions, next visit | Never. A note with no plan is incomplete. |
| Signature | Your name, credential, date and time, attribution for any later edits | Never. 42 CFR 482.24 requires every entry dated, timed, and authenticated. |
Copy it, drop the rows you don’t need for a given encounter, and you have SOAP, DAP, or a narrative scaffold. The two rows you can never cut are Assessment and Plan. Those carry the clinical weight, and they’re the two an audit reads first.
What does every progress note need to be defensible?
Whatever format you pick, a handful of things have to be true before the note is one you’d defend. We’ve anchored this to the federal record rule rather than to any vendor’s marketing, because the audit standard is what matters when someone pulls the chart.
42 CFR 482.24 requires entries to be “accurately written, promptly completed, properly filed and retained,” and “dated, timed, and authenticated.” CMS’s documentation guidance adds the content side: a note must reflect medical necessity, be legible and complete, and justify the service billed. The same CMS guidance warns specifically about “cloned” notes, ones that look identical across different visits, because they “may not reflect the uniqueness of the encounter.” That warning was written about copy-paste and templates. It applies word for word to an AI draft you didn’t read.
| Check before you sign | Why it matters |
|---|---|
| Nothing invented. No symptom, finding, or result the patient never reported or you never measured. | A confident wrong detail is worse than a blank field. You have to already know it’s wrong to catch it. |
| Nothing dropped. Every decision you made is in the Plan: the referral, the dose change, the safety advice. | A missing plan item is a missed action and a documentation gap a reviewer will find. |
| The Assessment is yours. Real clinical reasoning, not a paraphrase of the Subjective. | This is the section that shows medical necessity. A recycled Assessment doesn’t. |
| It doesn’t look cloned. This note reflects this visit, not last month’s with the date changed. | CMS flags cloned notes by name. An AI draft that reuses phrasing trips the same wire copy-paste does. |
| It’s dated, timed, and signed by you. Your credential, the correct time, edits attributed. | 42 CFR 482.24 makes this the baseline. The signature is you taking ownership of the content. |
Run a real note through this, not a demo. The note that matters is the one from your messiest visit, the patient who buried the real complaint in the last two minutes. A format change won’t save a sloppy note, and neither will a fast one.
Where AI Medical Scribe by Patient Square fits
The reason progress notes eat your evenings isn’t that the format is hard. It’s the volume. Primary-care physicians in a 2023 JAMA Network Open study logged a median of 36.2 minutes of EHR time per 30-minute visit, which the American Medical Association summed up the obvious way: the note now takes longer than the appointment. Pick whatever format you like; the typing is the tax.
AI Medical Scribe by Patient Square is an ambient AI medical scribe that listens during the visit and hands back a structured SOAP note, ICD-10 suggestions, and a prescription draft — ready to review and sign about two minutes after the visit. The default structure is SOAP, the format most clinicians and payers expect. The ICD-10 codes are suggestions, not automated coding; the prescription is a draft, not an order sent anywhere. The note is yours to read, edit, and sign. The draft saves the typing, not the judgment.
On the part that should decide any vendor: visit audio is processed in memory and discarded the moment the note is drafted. There’s no recording kept to retain, train on, or produce under a subpoena. Notes are encrypted in transit and at rest, access is role-scoped and logged, and the notes belong to your practice, which can export or delete any visit at any time. We map our safeguards to the HIPAA Security Rule and offer a BAA to every customer, and our SOC 2 Type II audit is underway.
The honest limit: if you write notes reflectively, as part of how you think a case through, a scribe is a poor fit no matter whose it is. If you need a format the default draft doesn’t produce, like BIRP for a managed-care contract, confirm the draft maps cleanly to your headings before you commit, since it drafts SOAP first. And we don’t write back into an EHR, so weigh that gap if you need the note to land automatically. For a clinician who just wants the documentation load off their evenings, a scribe that drafts a clean note and keeps none of your audio is a straight win.
The way to know is to grade a real note. To see a structured progress note appear about two minutes after a sample visit, book a demo, then run the 7-day free trial on your own visits and put three notes through the checklist above. If a tool can’t produce a sign-ready note on your hardest visit, no time-saved number will rescue it.