De-Identified Clinical Progress Notes & SOAP Drafts
Device-local note drafting for outpatient mental health counselors, psychotherapists, and clinical social workers.
Free Plan
100% unmetered browser drafting with discreet footer watermark "Verified by Outpatient Progress Notes Free".
- ✓ De-identified SOAP, DAP & BIRP progress notes
- ✓ Mental Status Exam (MSE) & diagnostic structuring
- ✓ 100% client-side privacy - zero PHI stored or transmitted
- ✓ Browser-based printable executive clinical note
- ✓ Discreet footer watermark: "Verified by Outpatient Progress Notes Free"
Outpatient Pro
Agency-grade clinical documentation, whitelabel practice letterhead, and audit-ready compliance tools.
- ✓ Custom clinic/private practice letterhead & logo
- ✓ Clinician state license # verification stamp (LCSW / LMFT / LPC / PsyD)
- ✓ Supervisor co-signature block for clinical supervision records
- ✓ 1-click quarterly CSV compliance export for audit & billing readiness
- ✓ Unwatermarked clinical records for official client files
Drafts stay on this device - nothing is uploaded.
Turn session details into a review-ready progress-note draft
Enter general, de-identified session details, choose the note shape, then review and edit the generated draft before marking it ready for your clinical completion.
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Start a de-identified session note
Use general details only - leave out names, dates of birth, contact details, and other identifying information.
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Clinical Deliverable
Executive Clinical SOAP Deliverable
Device-local, audit-ready clinical note with Mental Status Examination, risk assessment, and supervisory co-signature verification.
Beacon Valley Outpatient Behavioral Health & Psychotherapy
Outpatient Psychotherapy, Clinical Social Work & Counseling Services
100 Medical Center Way, Suite 400 • Clinical Records & Quality Review • Tel: (555) 382-9100
HIPAA Compliant Documentation • 45 CFR § 164.530 • Protected Health Information (PHI)
Subjective (Patient Chief Complaint, Reported Mood & History)
Chief Complaint & Stated Focus: Session 4 of CBT protocol for Major Depressive Disorder (moderate, recurrent). Client reports persistent low motivation, early morning awakenings, and automatic thoughts ('I can't accomplish anything meaningful') impacting work engagement.
Patient Stated Mood & Response: Client actively engaged in thought challenging exercise, identifying alternate balanced thought ('Tasks feel overwhelming, but starting small leads to completion'). Rated belief in original negative automatic thought decreased from 85% to 40%. Expressed receptivity to graded walking schedule.
Objective (Mental Status Examination & Clinical Observations)
In-Session Observations & Interventions: Maintained consistent eye contact; responsive to clinical guidance and active during session exercises.
Assessment (Diagnostic Impression, Treatment Progression & Risk Assessment)
Treatment Progression & Goal Progress: Client demonstrated increased cognitive flexibility and completed 4 of 7 scheduled mood logs from previous week. Depressive symptom score (PHQ-9) down from 16 to 12. Sleep hygiene adherence improving.
Formal suicide/homicide risk assessment not yet completed for this encounter. Clinician must evaluate and record risk status prior to clinical sign-off.
Plan (Interventions Delivered, Homework Assigned & Continued Care)
Interventions Delivered: Cognitive Restructuring & Behavioral Activation. Reviewed 7-day thought record identifying all-or-nothing cognitive distortions. Guided Socratic questioning to evaluate evidence for/against competence beliefs. Established graded task assignment for morning routine and scheduled two 20-min daily walks.
Homework & Between-Session Practice: Continue bi-weekly CBT protocol. Homework: Complete 3-column thought log during moments of midday procrastination; execute scheduled morning behavioral activation walking routine. Next session scheduled in 7 days.