Progress notes for OCD: keep the evidence specific
OCD can involve recurring unwanted thoughts, repetitive compulsive behaviors, or both. A note should record the actual concerns and work in the encounter rather than borrowing unrelated depression or generalized-anxiety examples. NIMH's OCD overview.
Documentation example, not treatment guidance. Adapt the structure to the encounter you actually conducted and your organization's requirements. A qualified clinician must review a real note; missing information must not be converted into a negative finding.
A fictional documentation example
Context: An adult with an established OCD diagnosis reports repeated door-lock checking before leaving home and says it delayed departure twice this week. During the encounter, clinician and client review the client's written record of those episodes. The client agrees to bring an updated record next time. No exposure exercise, symptom-scale result, medication review or risk assessment is supplied.
Reported concern: Client reports repeated lock checking and two delayed departures this week.
Work completed: Clinician and client reviewed the episode record and discussed the reported disruption to leaving home.
Response: Client reviewed the record and agreed to continue it. Change in symptom severity was not established from this encounter alone.
Plan: Review the updated record at the next encounter; confirm the follow-up date.
Do not add an intervention because it appears in a template
If an exposure and response prevention exercise or another intervention actually occurred, document its relevant details and the observed or reported response. If it did not occur, leave it out. The example above intentionally does not invent an exercise, improvement score or treatment recommendation.
Final review checklist
- Attribute reports and distinguish them from direct observations.
- Describe any stated functional effect in the context provided.
- Record actual assessments without substituting unrelated scale scores.
- Separate an agreed plan from an outcome already achieved.
- Resolve missing clinical information before signing a real record.
Progress-note structure · Observable documentation language.
Updated September 6, 2026.