Progress Notes for Multiple Diagnoses: Example & Template

What Is a Progress Note for Multiple Diagnoses?

A progress note for multiple diagnoses documents one session with a client who has two or more active diagnoses, such as ADHD, PTSD and depression, in a single note. Each diagnosis is tied to the symptoms you saw or heard that day, the interventions you used, how the client responded, and the treatment-plan goal the work served. This guide shows how to do that without writing the same observation three times. It includes a filled-in example for an adult with ADHD, PTSD and moderate major depression, and a downloadable template.

Several diagnoses in one person are ordinary in outpatient practice. The documentation problem is overlap. Poor sleep, low energy and trouble concentrating can each belong to more than one condition, so a note that lists every symptom under every diagnosis becomes long, repetitive and hard to audit. A note that lumps everything together fails the other way: a reviewer cannot tell which diagnosis the session treated, which goal moved, or whether a diagnosis on the claim was addressed at all.

The fix is structural. Record what the client reported and what you observed once. Then assess and plan by problem, numbered to match the treatment plan, so the line from diagnosis to goal to intervention to response (the golden thread) stays visible for every condition.

Diagnostic criteria for all three conditions in the example are set out in the DSM-5-TR. For plain-language overviews, see the American Psychiatric Association's What Is Posttraumatic Stress Disorder (PTSD)?, What Is Depression? and What Is ADHD? pages. For notes on one diagnosis at a time, see progress notes for PTSD, depression and ADHD.

When You Need It

• When a client's treatment plan lists two or more diagnoses that you are actively treating
• When one session works on goals that belong to different diagnoses
• When symptoms overlap and the record needs to show which condition you think a symptom reflects, or that you are not yet sure
• When the diagnosis chiefly responsible for today's session is not the one listed first on the treatment plan
• When a payer review or audit asks how each billed diagnosis connects to the services you delivered
• When a diagnosis is added, resolves, or changes severity partway through treatment
• When a substance use disorder sits alongside a mental health diagnosis (the substance use progress note guide covers the extra confidentiality rules)

Three Ways to Organize the Note

You can keep the format you already use, whether SOAP, DAP or BIRP (see SOAP vs. DAP vs. BIRP). What changes is how you divide the content inside it.

1. One integrated narrative, tagged by problem

The note reads as one account of the session, and each statement that belongs to a particular diagnosis carries a tag such as (P1) or (PTSD). It is quick to write and suits sessions where the conditions are tangled together. Its weakness is that a reviewer has to hunt through the whole note for the evidence behind any one goal.

2. Shared subjective and objective, assessment and plan by problem

The client's report and your observations are written once, because they describe one person in one session. The assessment and the plan are then split into a short block per problem (Problem 1 PTSD, Problem 2 depression, Problem 3 ADHD), each with its goal number, status and next step. This is the structure in the example below and in the downloadable template. It keeps the note short where overlap is greatest and specific where reviewers look hardest.

3. A full section for each diagnosis

Each diagnosis gets its own subjective, objective, assessment and plan. This maps neatly onto a goal-by-goal treatment plan, and some agencies require it, but it repeats itself whenever symptoms overlap, which with ADHD, PTSD and depression is most of the time. If you have to use it, write shared observations in the first section and point back to them ("see Problem 1 observations") instead of copying them.

Structure	Works best when	Watch for
Integrated narrative with tags	The conditions are tightly linked and sessions are short	Evidence for each goal is scattered
Shared S and O, assessment and plan by problem	Most outpatient sessions with two to four diagnoses	Keep each problem block brief and specific
Full section per diagnosis	Your agency or payer requires goal-by-goal notes	Copy-and-paste repetition across sections

Key Components — What to Document

The diagnosis list and today's focus

List each active diagnosis with its ICD-10-CM code and title, numbered the way the treatment plan numbers its problems. Mark the one that was chiefly responsible for this session; that is the diagnosis to list first for the encounter, unless an ICD-10-CM sequencing instruction such as a "code first" note puts another code ahead of it. Those instructions take precedence (Section IV.A of the ICD-10-CM Official Guidelines; see the coding section below). If a diagnosis on the list was not worked on today, say so in one line instead of leaving it out without comment.

Symptoms tied to each diagnosis

Describe what the client reported and what you observed in concrete terms: two nightmares this week rather than "sleep problems," three of five planned activities done rather than "low motivation." Attach each observation to the problem it bears on. Use your own clinical language. A progress note does not need to restate diagnostic criteria to support a diagnosis that was established at intake.

Overlapping symptoms, written once

ADHD, PTSD and depression share a lot of surface. Poor concentration can come from attention problems, from rumination, or from a night of broken sleep after a nightmare. Low energy can be depression, or the morning after a night of hypervigilance. Avoidance can be driven by trauma reminders or by the inertia of low mood. Irritability can belong to any of them.

Record each overlapping symptom one time, then say which problems you think it bears on and why: "Client links this week's poor focus at work to the two nights of nightmares (P1); it also slowed her activity schedule (P2) and her task list (P3)." When you cannot tell, write that down too, along with what you will watch to find out. An honest "unclear" is better documentation than assigning one complaint to three diagnoses so that each looks more active.

Interventions mapped to goals

Name each intervention and the problem it targeted. One intervention often serves more than one goal, and the note should say so. A weekly planning routine built for ADHD task management may also be the way a depression activity schedule gets carried out. Showing that link documents deliberate, integrated treatment rather than three unrelated mini-sessions.

Response and measures for each problem

Give every problem its own evidence of response. Standardized measures help when your treatment plan names them:

• PTSD: the PCL-5 total ranges from 0 to 80. The National Center for PTSD cites early research in which totals of 31 to 33 served as the cutoff for probable PTSD, and names tracking change over the course of treatment as one of the measure's purposes.
• Depression: the PHQ-9 total ranges from 0 to 27. Its instructions put the cutpoints at 5, 10, 15 and 20, where the mild, moderate, moderately severe and severe ranges begin.
• ADHD: many plans track functional targets, such as tasks submitted on time, appointments kept or bills paid, alongside or instead of a rating scale. Use whatever measure your treatment plan names and report it the same way every time.

Record the score, the date and the previous score so the trend is visible in one line. The outcome measures guide covers how to document scores across sessions.

Risk: one statement for the whole client

Risk belongs to the person, not to a diagnosis. Write a single risk statement that accounts for all active conditions, including suicidal and homicidal ideation, self-harm, changes in substance use and anything that has shifted since the last session, together with the action you took.

Plan by problem

For each problem, state the next intervention, any between-session task, and when the measure will be repeated. Then add what applies to the whole case: coordination with a prescriber or other provider, the next appointment, and whether the treatment plan needs revision.

Filled-In Example: Adult with ADHD, PTSD and Moderate Major Depression

The example below is fictional. It uses shared subjective and objective sections with a problem-by-problem assessment and plan. The problems keep their treatment-plan numbers, and PTSD (P1) is the first-listed diagnosis for this session because it was the main focus; depression and ADHD were also worked on. None of the three codes carries a "code first" note, so the session's focus sets the order.

When a session focuses on one diagnosis

Most weeks you will not work on every problem. Give the ones you did not target a one-line status so the record shows they are still being followed:

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Linking Each Diagnosis to the Treatment Plan

A note can only show a golden thread for each diagnosis if the treatment plan has one too. Every active diagnosis needs at least one goal, every goal at least one measurable objective, and every objective named interventions. The progress note then reports against those numbers. Using the example above:

Problem	Treatment-plan goal	Intervention this session	Evidence of response
P1 PTSD (F43.10)	Goal 1: reduce trauma-related avoidance and nightmares	Exposure review and next step; grounding	PCL-5 52 → 47 → 41; nightmares from 4–5 to 2 nights a week; first highway drive
P2 Depression, moderate (F32.1)	Goal 2: restore daily activity and lift mood	Activity scheduling tied to alarms	PHQ-9 14 → 12 → 11; 3 of 5 activities done
P3 ADHD, inattentive (F90.0)	Goal 3: use external structure for work and home tasks	Timer and checklist review; Sunday planning review added	On-time tasks from 2 of 9 to 6 of 9

If a diagnosis has no goal, either add one or ask whether the diagnosis belongs on the active list. If a goal goes several weeks without being worked on, the next note or plan review should say why: the problem is stable, it is waiting until another one settles, or the plan needs to change. For revision timing, see how often to update a treatment plan. For goal wording, see the PTSD, depression and ADHD treatment plan examples.

Diagnosis Order, Coding and Claims

• First-listed diagnosis. For outpatient encounters, the ICD-10-CM Official Guidelines say to list first the code for whichever condition the record shows was "chiefly responsible for the services provided," then add codes for coexisting conditions (Section IV.G). In practice that is usually the diagnosis the session mainly treated, which may change from week to week. ICD-10-CM's sequencing instructions, such as "code first" notes, take precedence over this rule (Section IV.A; see the next point). Some payers tie an authorization to one diagnosis and some EHRs carry the order forward automatically, so check both before you reorder.
• "Code first" notes. In choosing the first-listed diagnosis, ICD-10-CM's coding conventions and its general and disease-specific guidelines "take precedence over the outpatient guidelines" (Section IV.A). For mental health codes, the instruction to look for in the Tabular List is a "code first" note. F02.- (dementia in other diseases classified elsewhere) is never listed first: the underlying condition, such as Alzheimer's disease (G30.-), goes ahead of it (Section I.A.13). F06.- (other mental disorders due to known physiological condition) and F54 (psychological and behavioral factors associated with disorders or diseases classified elsewhere) also carry "code first" notes, so the physiological condition or physical disorder is listed ahead of them, even when the session treated only the mental health condition.
• Coexisting conditions. The same guidelines call for coding every documented condition present at the visit that requires or affects care, and say not to code conditions that were treated in the past and no longer exist (Section IV.J). A resolved diagnosis comes off the active list, with the change recorded in the treatment plan.
• Uncertain diagnoses. In outpatient settings, a diagnosis written as "rule out," "probable" or "suspected" is not coded; code what is established for that visit, which may be a symptom (Section IV.H). Keep the differential in your assessment (see the differential diagnosis template), not on the claim.
• Specificity and severity. Code as specifically as the record supports (Section IV.F.3). PTSD is a common case: in the ICD-10-CM index, post-traumatic stress disorder with no stated course goes to F43.10 (unspecified), and F43.11 (acute) and F43.12 (chronic) are for when the diagnosing clinician documents the course. The example uses F43.10 because that is the diagnosis recorded at intake; if the assessment documents the PTSD as chronic, F43.12 is the more specific code. When depression moves from moderate to mild or into partial remission, update the code (for example from F32.1 to F32.0 or F32.4) and the treatment plan together, with the reasoning in the note.
• Claims. On the CMS-1500, item 21 holds up to 12 ICD-10-CM codes, and the diagnosis pointer in item 24E links each service line to the codes it relates to, with the primary one first (NUCC instructions). The session is still one service: the psychotherapy code reflects time and type of service, not the number of diagnoses addressed. A different service on the same day, such as a case management contact, gets its own note. The ICD-10 code reference lists common mental health codes.

Common Mistakes

1. Copying the same symptom paragraph under every diagnosis. Repetition makes the note longer without making it stronger, and identical text in three sections stands out in an audit. Write it once and tag it.

2. Listing diagnoses the session did not touch as if they were treated. If a problem was not addressed, give it a status line that says so. Implying work that did not happen is a record-integrity problem, not a matter of style.

3. Letting a diagnosis go silent. A diagnosis that appears on every claim but in no assessment for two months invites the question of whether it is still active. Give it a status line or review the plan.

4. Writing "client is progressing" without naming the problem. With three diagnoses, a general progress statement tells a reviewer nothing. Say which goal moved, by how much, and on what evidence.

5. Counting one complaint three times. Poor sleep reported once is one symptom. Assign it where it belongs, or say the attribution is unclear; do not repeat it to support medical necessity for each diagnosis separately.

6. Treating a questionnaire band as the diagnosis. A PHQ-9 in the moderate range describes self-reported symptom burden. The severity in a major depressive disorder diagnosis is your clinical judgment, which also weighs functioning and history. The two usually move together, but one does not replace the other.

7. Not updating the plan when the diagnosis list changes. A new diagnosis, a resolved one, or a change in severity belongs in the treatment plan as well as the progress note.