Measurement-Based Care Symptom Scale Progress Note

Date: [encounter date]

Author: [clinician name and credentials]

Setting: [in-person / telehealth], [clinic / program]

MBC Context: [routine monitoring / baseline / post-intervention / medication change follow-up] — [reason for MBC review]

Measures & Results

(For each instrument administered, include a separate block. If a measure was attempted but not completed, document the reason. If no measures were administered, state this with brief rationale.)

[Instrument name and version]

• Completion: [respondent], [mode: portal / tablet / paper / interview], [language], [date completed]
• Total score & severity: [total score] — [severity category per instrument norms]
• Subscales: [key subscale scores and labels] (Include only if clinically relevant)
• Functional impact item: [response] (Include only if present in instrument)
• Risk-relevant items: [specific item(s) and response(s) above baseline] (Include only if endorsed)
• Interpretation: [one to two sentences linking score to clinical context; note concordance or discordance with interval history]

(Repeat block for each administered measure.)

If not completed: [Instrument name and version] — [reason not completed or not scorable]

If no measures administered: No standardized measures administered today — [brief rationale]

Trend

(Include only when prior scores exist for the same instrument. Omit this section entirely if no prior data are available.)

[Instrument name and version]

Scores: Current [score] ([date]); Prior [score] ([date]); Baseline [score] ([date]) (if available). Δ from prior: [value]; Δ from baseline: [value]. Clinically meaningful change: [yes / no / threshold not established for this instrument].

[One to two sentences synthesizing trajectory: direction of change, timeframe, and relevant context such as medication adherence, therapy engagement, or psychosocial stressors]

(Repeat block for each instrument with prior data.)

Risk Review

(Include only if any risk-relevant item is endorsed above "not at all" or if any safety concern arises during the encounter. Omit this section if no risk items endorsed and no safety concerns identified.)

• Trigger: [specific item and response prompting review]
• Same-day evaluation: [performed / declined]. [If performed: summarize ideation characteristics, plan, intent, behaviors, key risk and protective factors. If declined: document refusal and counseling provided.]
• Risk level: [per organizational framework]
• Mitigation actions: [safety plan updates, means counseling, referrals, crisis resources provided, disposition as applicable]
• Follow-up plan: [timeframe], [responsible party]

Assessment & Plan

Assessment: [Brief clinical interpretation linking scale results to active diagnoses; note concordance or discordance between scores, mental status examination, and patient-reported functioning]

• Medications: [changes with rationale tied to symptom trajectory / continue current regimen — rationale]
• Psychotherapy: [initiated / continued / modified] — [modality and focus with rationale based on measures]
• Referrals: [referrals indicated / none indicated]
• Next measurement plan: [instrument(s)], [timing], [rationale]
• Patient engagement: Results reviewed with patient. [Patient perspective on accuracy or meaning of scores, particularly if discordant with clinician interpretation]

(If no changes indicated: "Continue current plan — [brief rationale based on stable or improving trajectory].")