Insurance rejecting therapy claims for “vague progress notes” - what do they want?

Brief Answer

When insurers say “vague progress notes,” they usually mean that the note does not clearly show three things: why treatment is still medically necessary, what you actually did in the session, and how the client responded in a way that relates to the treatment plan and to function in daily life.

They generally want: a specific problem or target symptom, interventions by the clinician, client response and change since last session, functional impact, risk and safety if relevant, and a plan that connects to the treatment goals. Avoid copy and paste language, very generic phrases, and notes that say “client stable” without showing what that means.

The Longer Answer

Think of it as answering four questions in every note: Why today, what did we work on, what changed, and what is the plan.

A. Common reasons insurers label notes “vague”

• Symptoms or problems described only in very general terms
• No clear link between symptoms and functional impairment
• Interventions not named or described
• Client response summarized in one generic sentence
• No visible change over time, especially in long term treatment
• No clear connection between the session and the treatment plan or diagnosis
• Extensive reuse of identical wording across many notes

If a reviewer cannot understand what you did, why it mattered clinically, and how it ties to the diagnosis and goals, they are more likely to deny for “vague” or “medical necessity not supported.”

B. What insurers usually expect in each core element

You do not need long notes, but you do need these ingredients in clear, specific language.

C. “Vague” vs “clear” examples

If your notes mostly look like the “vague” column, that is exactly what insurers are flagging.

D. How to tie notes to treatment plans and diagnosis

Insurers want to see that the session is moving a treatment plan forward and is not just “supportive listening” forever.

You can keep it simple:

• Start from the goal
  • “Reduce panic attacks to less than 1 per week and return to full work attendance.”
• In the note, show how today’s work connects
  • “Today focused on exposure planning for morning commute, which directly targets panic episodes that cause late arrivals.”
• Name the diagnosis in your assessment or plan
  • “Symptoms remain consistent with Panic Disorder without agoraphobia.”

That link between diagnosis, goal, and what you did today is the “medical necessity story” reviewers are looking for.

E. Quick checklist before you sign a note

Ask yourself:

• Did I name a specific problem or symptom, not just a general theme?
• Is there at least one sentence that shows functional impact or risk?
• Is at least one intervention clearly described by type or technique?
• Does the note say how the client responded, not only that they were “engaged”?
• Is there a clear next step that fits the treatment goal?
• If someone read only this note, would they understand why therapy is still needed?

If the answer is yes to most of these, your note is rarely “vague” in the way payers mean it.