What information should be included in an assessment progress note?
 The assessment progress note must include a statement about the reason for the assessment that day and at least one of the following elements:

  • gathering history of presenting problem
  • performing a mental status exam
  • psychological testing
  • obtaining information about relevant cultural variables
  • obtaining information to clarify the diagnosis
Basically it is only a collection of information that will be helpful for the clinician in their development of their diagnosis. In that sense, you do not need a clinical intervention, but rather a plan. This is what makes the assessment note different from a case mgmt note or treatment note.
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