How do you write a progress note for insomnia?

Record the sleep diary averages since the last session and how they compare with baseline, the daytime effects, the CBT-I step or other technique you used and the goal it serves, how the client responded and any measure score such as the ISI, and the plan for the next week, including any change to the sleep window. Add risk screening and any referral for a medical sleep assessment.

What should a sleep diary include?

One row per night with the time the client got into bed and turned the lights out, how long it took to fall asleep, how many times they woke and for how long, the final wake time and time out of bed, a sleep quality rating, and naps, caffeine and alcohol. Bring the weekly averages into the progress note.

What is the ICD-10 code for insomnia in therapy?

DSM-5-TR codes insomnia disorder as F51.01 in ICD-10-CM. Insomnia caused by a medical condition, a substance or another sleep disorder is coded differently, and G47.00 is the general medical code for insomnia, unspecified. Use the code that matches your assessment and the payer’s rules.

How do you calculate sleep efficiency?

Divide total sleep time by total time in bed and multiply by 100. For example, 6 hours asleep in 7 hours in bed is about 86%. In CBT-I the weekly average is often used to decide whether to keep, shorten or extend the sleep window.

When should a therapist refer a client with insomnia to a doctor?

Refer for a medical assessment when the client reports loud snoring, gasping or pauses in breathing, restless legs, falling asleep while driving or at work, or when insomnia may be caused by a medical condition or medication. Before sleep restriction, coordinate with the medical team for clients with bipolar disorder, seizure disorders or safety-sensitive jobs.

Progress Notes for Insomnia: Template + Examples (2026)

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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.

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Short answer: an insomnia progress note records what the client’s sleep diary showed since the last session (time to fall asleep, time awake during the night, total sleep and time in bed), how poor sleep affected the day, the CBT-I or other technique you used and the goal it serves, how the client responded, and the plan for the next week, including any change to the sleep window. Use the client’s own numbers rather than “sleeping better.”

Insomnia disorder in DSM-5-TR (F51.01 in ICD-10-CM) means difficulty falling asleep, staying asleep or waking too early on at least 3 nights a week for at least 3 months, despite enough opportunity to sleep, with distress or daytime impairment. Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia in adults. Its parts, such as stimulus control, sleep restriction, cognitive work on sleep worries and relaxation, are easy to name in the note. Insomnia often occurs with depression, anxiety, PTSD and chronic pain; record how they interact. The table shows what goes in each section.

What to document in an insomnia progress note

What to document in each progress note section, with fictional example wording
Section	What to document	Example wording
Session Summary	Sleep diary averages for the week, compared with baseline	“Diary, 7 nights: time to fall asleep about 30 minutes (75 at intake); awake about 40 minutes a night; total sleep about 5.5 hours; sleep efficiency about 82% (61% at intake).”
Session Summary	Daytime effects and what the client did when awake at night	“Less tired at work, napped once. Got out of bed when awake longer than about 20 minutes on 5 of 7 nights.”
Session Summary	Caffeine, alcohol, medication and other sleep factors, as reported	“One coffee before noon; no alcohol on weeknights; no change to medication prescribed by her primary care provider.”
Interventions	The CBT-I step, its purpose and the goal it serves	“Reviewed the diary and extended the sleep window by 15 minutes because sleep efficiency was over 85% for most nights.”
Client Response	What the client said and did, and measure scores	“Insomnia Severity Index 12 today (19 at intake). Client: ‘The hardest part is getting up when I can’t sleep.’”
Client Response	Mood and risk screening	“PHQ-9 6. Screened for suicidal thoughts: denied.”
Plan Updates	New sleep window, practice, referrals and next session	“Sleep window 11:15 p.m. to 6:15 a.m.; continue stimulus control and the diary; next session in 1 week.”

Sleep diary template for insomnia

Ask the client to fill in one row each morning. Bring the averages into the progress note rather than every night.

Sleep diary columns, one row per night (fictional example row)
Date	In bed / lights out	Time to fall asleep	Times awake and total minutes	Final wake / out of bed	Sleep quality (1–5)	Naps, caffeine, alcohol
Mon 12 Oct	10:45 p.m. / 11:00 p.m.	35 min	2, about 45 min	6:00 a.m. / 6:15 a.m.	3	No nap; 1 coffee 8 a.m.; no alcohol

Sleep efficiency is total sleep time divided by time in bed, times 100. If the client reports loud snoring, gasping or pauses in breathing, restless legs, or very sleepy driving, refer them to their medical provider for assessment of a sleep disorder and record the referral. Sleep restriction needs extra care for clients with bipolar disorder, seizure disorders or jobs where sleepiness is dangerous; coordinate with the medical team before using it. Record what the client reports about sleep medication and leave medication decisions to the prescriber.

How to Document Progress Notes for Insomnia & Sleep Disorders

Session Summary

Overview of session focus, topics discussed, and client presentation

When documenting the Session Summary for insomnia, record the client's self-reported sleep difficulties, specific symptoms, potential triggers, and observed mood or affect related to their sleep issues during the session.

Client's description of sleep onset latency, number and duration of night awakenings, and early morning awakenings
Identification of recent or ongoing stressors or lifestyle factors contributing to insomnia symptoms
Client's reported daytime impairments such as fatigue, concentration difficulties, or irritability linked to poor sleep
Observation of client's mood and affect, noting any signs of anxiety, frustration, or depressive symptoms related to insomnia
Noting any changes in sleep patterns or symptoms since the last session

Interventions

Therapeutic techniques and interventions applied during the session

In the Interventions section for insomnia, detail the specific clinical techniques, behavioral strategies, and therapeutic modalities applied during the session to address the client's sleep difficulties.

Implementation of sleep hygiene education tailored to the client's habits and environment
Use of cognitive-behavioral therapy for insomnia (CBT-I) techniques such as stimulus control or sleep restriction
Application of relaxation training methods including progressive muscle relaxation or guided imagery
Introduction or review of sleep diary usage to monitor sleep patterns and triggers
Discussion and practice of mindfulness or breathing exercises aimed at reducing pre-sleep arousal

Client Response

Client's reaction to interventions and observable progress

The Client Response section should capture the client's engagement, emotional and cognitive reactions to the interventions for insomnia, as well as any clinical impressions about progress or diagnostic considerations.

Client's reported adherence to and perceived effectiveness of prescribed sleep hygiene and behavioral techniques
Expression of any challenges or barriers encountered implementing the interventions
Observation of changes in client's motivation or confidence regarding managing insomnia
Assessment of any noticeable improvement or worsening in sleep quality or daytime functioning
Clinician’s impression of how insomnia interacts with any co-occurring condition, such as depression, anxiety, PTSD or chronic pain

Plan Updates

Changes to treatment plan, goals, and next session focus

In the Plan Updates section for insomnia, outline the next steps in treatment, including homework assignments, adjustments to the current plan, referrals, and scheduling of future sessions.

Assigning specific sleep diary completion or relaxation exercises as homework before the next session
Modifying treatment goals or techniques based on client progress and response
Referral to a sleep specialist or psychiatrist if symptoms suggest a need for medical evaluation
Scheduling follow-up sessions with frequency adjusted according to treatment needs
Planning to introduce or escalate cognitive restructuring techniques if maladaptive sleep beliefs persist