Writing Better Access Progress Reports in Half the Time

What the Report Must Contain

The Department of Health does not publish a mandatory template for Better Access progress reports, but AHPRA and Medicare guidelines, along with professional standards from the Australian Psychological Society (APS), establish clear expectations about content.

A compliant progress report should include:

Client and Referral Information

• Client name and date of birth
• Referring GP name and practice
• Date of original referral and MHTP
• Number of sessions attended (e.g., '6 of 10 allocated sessions')

Presenting Issues

• The presenting problems as identified at intake
• Brief description of the client's initial presentation, including severity
• Relevant psychosocial context (only what the GP needs to know)

Treatment Provided

• Treatment modality used (e.g., Cognitive Behavioural Therapy, Acceptance and Commitment Therapy, Schema Therapy)
• Key treatment targets or goals
• Brief summary of interventions applied (without session-by-session detail)

Outcome Measures

• Validated outcome measure used (e.g., PHQ-9, GAD-7, K10, DASS-21)
• Pre-treatment score and post-treatment (or mid-treatment) score
• Clinical interpretation of the change (e.g., 'PHQ-9 score decreased from 18 (moderately severe) to 11 (moderate), indicating clinically meaningful improvement')

Current Status and Recommendations

• Current clinical presentation
• Whether treatment goals have been met, partially met, or remain ongoing
• Recommendation: continue treatment (and how many additional sessions), discharge, or referral to another service
• Any medication considerations for the GP to review (without prescribing)

Risk Assessment

• Current risk status (if applicable)
• Safety plan in place (if applicable)

What Can Be Omitted

One of the most common mistakes psychologists make in GP progress reports is including too much clinical detail. The GP does not need (and generally does not want) to know the specific content of therapy sessions, detailed case formulations, or session-by-session notes.

You can and should omit:

• Detailed session content. The GP does not need to know what the client discussed in session 3. They need to know the treatment modality, the treatment focus, and the outcome.
• Full case formulation. A brief formulation statement is sufficient. Save the comprehensive formulation for your clinical file.
• Personal disclosures. If the client shared sensitive information in session (e.g., childhood trauma details, relationship difficulties), this should not appear in a GP report without the client's explicit consent. The report should focus on the clinical picture, not the narrative.
• Jargon-heavy theoretical explanations. Write for a GP audience. 'Cognitive restructuring targeting catastrophic thought patterns' is clearer than 'phase 2 schema therapy work addressing the Defectiveness/Shame and Emotional Deprivation early maladaptive schemas through limited reparenting and empathic confrontation.'

The Dictation-First Workflow

The traditional approach to writing a progress report involves sitting at your computer, reviewing session notes, pulling together outcome scores, and composing the report in a word processor or practice management system. This process typically takes 30 to 45 minutes per report.

The dictation approach is significantly faster. Here is the workflow:

Step 1: Prepare Your Data (2 minutes)

Before dictating, quickly review:

• Number of sessions attended
• Pre and post outcome measure scores
• The treatment modality and key interventions used
• Your recommendation for ongoing treatment

If you have been maintaining good session notes, this information is at your fingertips. If you use a platform like Grounded Scribe, your session notes and outcome scores are already structured and accessible.

Step 2: Dictate the Report (2 to 3 minutes)

Using your AI scribe's dictation mode, speak the report content naturally. A typical dictation might sound like this:

'Progress report for Sarah Chen, date of birth 15 March 1988, referred by Dr James Wong of Eastside Medical Centre, MHTP dated 3 September 2025. Sarah has attended 6 of 10 allocated sessions between September 2025 and January 2026.

Presenting issues at intake were moderate to severe generalised anxiety and associated sleep disturbance. PHQ-9 at intake was 8 indicating mild depression, GAD-7 was 14 indicating moderate anxiety.

Treatment has been Cognitive Behavioural Therapy focusing on cognitive restructuring of worry-related cognitions, behavioural experiments targeting avoidance, and sleep hygiene psychoeducation.

Current outcome scores: PHQ-9 is 5 indicating minimal depression, GAD-7 is 8 indicating mild anxiety. Both scores represent clinically meaningful improvement.

Sarah reports improved sleep quality, reduced frequency and intensity of worry episodes, and increased engagement in previously avoided social activities. She continues to experience some anticipatory anxiety in work-related situations which remains a treatment target.

Recommendation is to continue treatment for the remaining 4 allocated sessions focusing on workplace anxiety management and relapse prevention. No medication changes recommended at this time. Risk assessment: no current risk concerns.'

This dictation takes approximately 2 to 3 minutes.

Step 3: AI Generates Formatted Report (30 seconds)

The AI scribe converts your dictation into a structured, professionally formatted progress report with appropriate headings, clinical language, and layout. The report uses your dictated content as the foundation but presents it in a polished format suitable for sending to a GP.

Step 4: Review and Finalise (2 to 3 minutes)

Review the generated report for accuracy. Check that:

• Outcome scores are correctly recorded
• The treatment modality is accurately described
• Your recommendation is clearly stated
• No clinical content has been added or misinterpreted by the AI
• The tone and language are appropriate for a GP audience

Make any necessary edits and the report is ready to send.

Total Time: 7 to 10 Minutes

Compare this to the traditional approach of 30 to 45 minutes per report. For a psychologist writing 5 progress reports per month, this workflow saves approximately 2 to 3 hours. For those with larger caseloads, the savings scale proportionally.

How Much Clinical Detail Should You Share?

This is one of the most nuanced questions in Better Access reporting. The answer depends on several factors:

Client consent. Always discuss with the client what will be included in the GP report. Some clients are comfortable with a general summary; others have strong preferences about what is shared. Document this discussion.

Clinical relevance for the GP. If the client's anxiety is significantly impacted by a medical condition (e.g., chronic pain, thyroid disorder), the GP needs to know. If the anxiety is primarily related to workplace stress, the GP needs a general summary, not a detailed workplace narrative.

Risk information. If there are current or recent risk concerns, the GP must be informed. This is a duty of care that overrides client preferences in most circumstances, though the client should be informed about what will be communicated.

Medication considerations. If you believe the client might benefit from pharmacological support, or if current medication appears to be affecting symptoms, include this as a recommendation for the GP to consider. Be careful to frame this as a clinical observation rather than a prescribing recommendation.

Handling the 6-Session and 10-Session Reports

Common Pitfalls

Sending reports late. GPs rely on timely reports to manage their patients' care. Aim to send the progress report within one week of the relevant session. Batching reports monthly is acceptable but less ideal.

Forgetting outcome measures. A report without pre and post outcome scores lacks the quantitative evidence that GPs find most useful. Always include at least one validated measure.

Overwriting. A two-page report is sufficient for most Better Access progress reports. If your reports regularly exceed three pages, you are likely including too much detail.

Not including your provider number. The GP may need your provider number for administrative purposes. Include it in your sign-off.

Streamlining the Process

The biggest time savings come from establishing a consistent workflow:

1. Maintain good session notes throughout treatment (so you are not reconstructing 6 sessions of work at report time)
2. Track outcome measures systematically (ideally in your practice management system or documentation platform)
3. Use a dictation-first workflow to generate the report draft
4. Keep a standard structure so that you are not redesigning the report format each time

Grounded Scribe supports this workflow with structured session documentation, integrated assessment tracking, and dictation-based report generation. Visit our page for psychologists for more details on how the platform supports Better Access documentation.

Start your 14-day free trial at Grounded Scribe.

Disclaimer

*Grounded Scribe is a documentation tool that assists practitioners in structuring their clinical notes. All AI-generated content must be reviewed, edited, and approved by the practitioner before it becomes part of the clinical record. The practitioner retains full professional responsibility for the accuracy, completeness, and clinical appropriateness of all documentation.*

---