Progress Notes for Grief and Loss: Example and Template
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.
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Short answer: a grief progress note records the loss and when it happened, how grief has shown up in the client’s daily life since the last session (sleep, work, relationships, routines and rituals), what you did in session, how the client responded, the risk screening you did, and the plan. Describe grief in the client’s words and in terms of function. Most grief is a normal response to loss and does not need a diagnosis.
DSM-5-TR prolonged grief disorder applies only when the death was at least 12 months ago for adults (at least 6 months for children and adolescents), with intense yearning for or preoccupation with the person who died, plus at least 3 further symptoms (such as identity disruption, intense emotional pain, avoidance of reminders or intense loneliness), nearly every day for at least the last month, causing significant distress or impairment and exceeding cultural, religious or social norms.
What to document in a grief and loss progress note
| What to document | Example wording |
|---|---|
| The loss: who, when and how, as the client describes it | “Client’s father died 7 months ago after a long illness.” |
| Grief since the last session: yearning, waves of sadness, sleep, triggers, anniversaries | “Reported waking at 4 a.m. most nights and crying on Sunday afternoon, the time of their usual phone call.” |
| Functioning: work or school, relationships, self-care, valued activities | “Back at full-time work and managing workload; declined 2 invitations from friends.” |
| What you observed in session | “Tearful describing the hospital stay; brighter affect when sharing memories of their calls.” |
| Intervention and its purpose | “Normalized grief responses; invited a story about her father; introduced a letter-writing exercise to support the goal of talking about the loss.” |
| Response, with a rating where you can | “Distress 7/10 at the start, 4/10 at the end; said she felt ‘lighter.’” |
| Risk screening and the result | “Screened for suicidal thoughts and thoughts of wanting to die: denied both.” |
| Plan | “Continue the letter at home if she chooses; one weekend walk with a friend; next session in 1 week.” |
How to Document Progress Notes for Grief & Bereavement
Session Summary
Overview of session focus, topics discussed, and client presentation
When documenting the Session Summary for grief and loss, capture the client’s reported emotional and physical symptoms, specific grief-related concerns, any identified triggers, and the overall mood and affect observed during the session.
- Document client-reported intensity and frequency of grief-related emotions such as sadness, anger, guilt, or numbness.
- Note any recent or ongoing grief triggers identified by the client, including anniversaries, reminders, or changes in routine.
- Summarize presenting concerns related to loss, such as difficulty accepting the loss, intrusive memories, or feelings of emptiness.
- Describe the client’s observed mood and affect, noting congruence or incongruence with reported feelings of grief.
- Record any physical symptoms linked to grief, such as fatigue, changes in appetite, or sleep disturbances.
Interventions
Therapeutic techniques and interventions applied during the session
In the Interventions section for grief and loss, detail the therapeutic techniques and modalities employed, clinician observations of client engagement, and strategies tailored to support grief processing and coping.
- Specify use of grief-specific therapeutic approaches such as narrative therapy, meaning-making, or imaginal conversations with the deceased.
- Note clinician observations of client’s emotional responsiveness and engagement with the interventions.
- Document any grounding or relaxation techniques introduced to manage acute grief distress or anxiety.
- Record use of cognitive restructuring or reframing methods aimed at addressing maladaptive grief-related thoughts.
- Describe application of psychoeducation about grief stages, normalizing symptoms and setting expectations.
Client Response
Client's reaction to interventions and observable progress
Document the client’s reactions and progress related to grief work, including emotional shifts, cognitive insights, and any changes in symptom severity or functioning observed during the session.
- Note client’s verbal and nonverbal responses to grief-focused interventions, including resistance or openness.
- Evaluate any reported changes in grief intensity, such as reduction in intrusive thoughts or emotional numbness.
- Record client’s emerging insights or new perspectives about their loss and personal coping mechanisms.
- Assess any diagnostic considerations or symptom escalation that may indicate complicated grief or comorbid conditions.
- Describe client’s expressed readiness or hesitancy to engage in deeper grief processing or future therapeutic tasks.
Plan Updates
Changes to treatment plan, goals, and next session focus
In the Plan Updates section for grief and loss, outline next steps including therapeutic goals, homework assignments, treatment adjustments, referrals, and scheduling plans tailored to support ongoing grief resolution.
- Specify planned therapeutic focus for upcoming sessions, such as exploring unresolved emotions or rebuilding meaning.
- Assign grief-related homework tasks like journaling memories, creating a ritual, or practicing self-care activities.
- Indicate any modifications to treatment approach based on current client status, such as introducing group therapy or trauma-focused techniques.
- Document referrals to additional supports, such as grief support groups, psychiatric evaluation, or community resources.
- Confirm scheduling of next session(s) with consideration for client’s emotional state and availability.
SOAP Notes for Grief And Loss
Alternative format for documenting grief and loss
DAP Notes for Grief And Loss
Alternative format for documenting grief and loss
BIRP Notes for Grief And Loss
Alternative format for documenting grief and loss
SIRP Notes for Grief And Loss
Alternative format for documenting grief and loss
GIRP Notes for Grief And Loss
Alternative format for documenting grief and loss
PIE Notes for Grief And Loss
Alternative format for documenting grief and loss
Grief and loss progress note example
Fictional documentation example, not treatment guidance. Adapt it to the session you actually conducted and your organization’s requirements.
Session Summary: Fictional adult client, session 4. Client’s father died 7 months ago after a long illness. Treatment-plan goal: resume two activities she has stopped (choir and weekend walks with a friend) and talk about her father with family. Client reported waking at 4 a.m. on most nights and crying on Sunday afternoon, the time of their usual phone call. She returned to full-time work three weeks ago and is managing her workload, but declined two invitations from friends. Client stated: “I keep picking up the phone to call him.”
Interventions: Provided information about common grief responses, including waves of grief around routines and anniversaries. Invited the client to tell a story about her father and to name what she misses most. Introduced a letter-writing exercise addressed to her father. Reviewed her sleep routine and agreed one small step toward a valued activity.
Client Response: Client was tearful describing the hospital stay and brighter describing their phone calls. Rated distress 7/10 at the start and 4/10 at the end, and said she felt “lighter.” She chose to start the letter at home and agreed to join one weekend walk.
Safety: Screened for suicidal thoughts and thoughts of wanting to die: client denied both. No other safety concerns identified.
Plan Updates: Client may bring the letter to the next session if she wishes. Client will go on one weekend walk. Discussed a local bereavement support group as an option; client will consider it. Next session in one week; continue to monitor sleep and functioning.
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Tips for Progress Notes for Grief & Bereavement
Describe grief without pathologizing it
Most grief is a normal response to loss. Describe what the client experiences (yearning, waves of sadness, sleep changes) and how it affects daily life, and avoid diagnostic language unless the criteria for a disorder are met.
Know the prolonged grief disorder thresholds
DSM-5-TR prolonged grief disorder needs the death to be at least 12 months ago for adults (6 months for children and adolescents), with yearning or preoccupation and at least 3 further symptoms nearly every day for at least the last month, causing significant distress or impairment beyond cultural norms. Before that point, document grief and any other conditions on their own terms.
Track function, not just feelings
Record the same few things each session: distress on a 0–10 scale, sleep, work or school, contact with others and return to valued activities. “Declined 2 invitations; back at choir once” shows change in a way that “grieving” cannot.
Ask about risk and record the answer
Ask directly about suicidal thoughts, especially when a client talks about wanting to be with the person who died, and document the answer. If the screen is positive, record the client’s words, any plan, intent, history and access to means, your risk formulation and the actions you took.
Note other conditions separately
Depression, PTSD after a sudden or traumatic death, and substance use can occur alongside grief. If you assess for them, document the findings and any measure score with its date rather than folding them into “grief.”
Record what matters to the client culturally
Note the mourning rituals, beliefs and supports that matter to the client. What counts as a typical grief response varies across cultures and religions, and the plan should fit the client’s practices.
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Further Reading
- SAMHSA — Provides resources and best practices for behavioral health documentation including grief and bereavement.
- APA Documentation Guidelines — Offers detailed guidance on clinical documentation standards relevant to mental health professionals.
- DSM-5-TR — Includes diagnostic criteria and clinical considerations for grief-related disorders important for accurate documentation.