How do you write a progress note for borderline personality disorder?

Record diary card targets, self-harm and suicidal thoughts, and skills used in the Session Summary; the chain analysis or skills work in Interventions; the client’s response, a full risk assessment and progress in Client Response; and skills practice, safety-plan updates and the next session in Plan Updates.

How do I document self-harm in a progress note?

Record what happened, when, the method and the injury, whether medical care was needed, the events that led to it, any suicidal intent, and a full risk assessment with your formulation. Note the skills the client could use next time and any change to the safety plan.

What is a chain analysis in DBT?

A chain analysis is a step-by-step review of a problem behavior: the vulnerability, the prompting event, the thoughts, feelings and actions that followed, the behavior itself and its consequences. It identifies where a skill could break the chain, and a short summary belongs in the note.

Is “contracted for safety” enough documentation?

No. No-suicide contracts are not shown to prevent suicide and do not show that risk was assessed. Record the risk assessment, your formulation and a safety plan that lists warning signs, coping steps, contacts and crisis lines.

What is the ICD-10 code for borderline personality disorder?

Borderline personality disorder is coded F60.3 in ICD-10-CM. Record the code that matches your diagnosis and the payer’s requirements.

Progress Notes for Borderline Personality Disorder: Example and Template

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Overview

This guide is part of our complete progress notes hub — format structure, a full clinical example, the progress note generator, and all 72 diagnosis-specific templates.

No sign-up needed: open a fictional note in the MentalNote editor and edit it like a real draft.

Short answer: a progress note for borderline personality disorder (BPD) records the week’s target behaviors and emotions (often from a diary card), any self-harm or suicidal thoughts, and skills used in the Session Summary; the specific intervention, such as a chain analysis or skills coaching, in Interventions; the client’s response, a full risk assessment and progress toward goals in Client Response; and skills practice, safety-plan updates and the next session in Plan Updates.

People with BPD may have long-standing, recurring suicidal thoughts as well as periods of higher, acute risk, so the note should show both: the client’s usual pattern and what is different this week. When self-harm or suicidal thoughts are reported, record current thoughts, plan, intent, preparatory behavior, past attempts, access to means, protective factors, your risk formulation and the safety plan, not just “SI denied” or “contracted for safety.” In dialectical behavior therapy (DBT), name the skills module and the specific skill, and keep a record of between-session coaching contacts.

What to document in a BPD progress note

What to document in each progress note section for borderline personality disorder, with fictional example wording
Section	What to document	Example wording
Session Summary	Diary card targets and emotions	“Diary card: self-harm urges on 4 days (max 4/5), one act of self-harm; suicidal thoughts on 1 day (2/5).”
Session Summary	Skills used and coaching contacts	“Used TIPP twice and opposite action once; one phone coaching call.”
Interventions	Chain analysis or skills work	“Chain analysis of Saturday’s self-harm: argument, shame, ‘I ruin everything,’ cut forearm; repair and solution steps identified.”
Client Response	Risk assessment after self-harm or suicidal thoughts	“Medical assessment of cuts reported; denied intent to die during cutting and current suicidal thoughts, plan or intent; self-harm urge 0/5; past attempt 2 years ago; sharps and excess medication secured. See the full risk formulation below.”
Client Response	Engagement and progress	“Completed the chain analysis; generated 2 alternative skills; self-harm acts 3 to 1 a week since intake.”
Plan Updates	Skills practice, safety plan, next session	“Practice TIPP at urge 3/5; safety plan updated with sister as a contact. Next session in 1 week; skills group Thursday.”

Ask about recent self-harm injuries, document any medical assessment and its source, and arrange medical evaluation when indicated or when wound severity is uncertain; stay within your clinical scope. Escalate when risk changes: a new plan, stated intent, preparatory behavior or a sharp rise in hopelessness calls for a fuller assessment, more contact or a higher level of care. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.

How to Document Progress Notes for Borderline Personality Disorder

Session Summary

Overview of session focus, topics discussed, and client presentation

When documenting the Session Summary for borderline personality disorder, capture the client’s self-reported symptoms, specific presenting concerns, identifiable emotional or situational triggers, and observed mood or affect fluctuations during the session.

Note any reported instances of emotional dysregulation or mood swings since the last session.
Document descriptions of interpersonal conflicts or fears of abandonment presented by the client.
Identify and record any situational triggers that elicited intense emotional responses or impulsive behaviors.
Summarize the client’s affect range and stability observed throughout the session.
Highlight any expressions of suicidal ideation, self-harm urges, or dissociative experiences shared by the client.

Interventions

Therapeutic techniques and interventions applied during the session

In the Interventions section for borderline personality disorder, detail the therapeutic techniques and modalities employed to address emotional instability, interpersonal difficulties, and maladaptive coping patterns observed during the session.

Describe use of dialectical behavior therapy (DBT) skills such as distress tolerance or emotion regulation.
Note implementation of cognitive restructuring techniques targeting black-and-white thinking.
Record clinician observations of client’s engagement with mindfulness or grounding exercises.
Detail any role-playing or validation strategies used to improve interpersonal effectiveness.
Indicate use of crisis intervention methods considering suicidal ideation or self-injurious behavior.

Client Response

Client's reaction to interventions and observable progress

The Client Response section should document the client’s reactions to interventions, observable progress or setbacks in symptom management, and any shifts in diagnostic presentation or insight during the session.

Evaluate the client’s ability to apply taught coping skills during emotionally charged discussions.
Assess changes in insight regarding interpersonal patterns or emotional triggers.
Note client’s verbal and nonverbal responses to therapeutic techniques introduced.
Record any emergent diagnostic considerations based on new symptom reports or behaviors.
Comment on the client’s expressed motivation or resistance toward treatment goals.

Plan Updates

Changes to treatment plan, goals, and next session focus

Plan Updates for borderline personality disorder should outline tailored next steps including homework assignments focused on skill practice, any necessary treatment modifications, referrals for adjunctive services, and scheduling of upcoming sessions.

Assign specific DBT homework tasks such as tracking mood or practicing distress tolerance skills.
Adjust treatment goals or modalities based on client progress and emerging needs.
Recommend referrals for psychiatric evaluation or adjunctive therapies if indicated.
Schedule follow-up sessions emphasizing frequency adjustments to support crisis management.
Plan collaborative review of risk management strategies including safety planning.