Therapist Session Notes

Writing effective therapist session notes may not be a clinician’s favorite part of the job. Documentation takes time and, given our full caseloads, many therapists only have time to write notes at the end of a busy day. 

To help reduce therapists’ workload, the SimplePractice EHR contains therapy notes tools, including a library of customizable intake forms, treatment plans, and assessments.

This article shares a quick overview of how to write therapy notes, provides key information to include, different note taking formats, and top tips for writing quick and succinct notes.

What are therapist session notes?

While there are no hard and fast rules for therapy sessions documentation, there are laws protecting therapy notes, and ethical guidelines about what to include in your documentation. 

Session notes contain sensitive information protected under the Health Insurance Portability and Accountability Act (HIPAA) and must be protected in either a locked cabinet or password protected computer.

Therapist session notes should contain a brief record of a clinical encounter with an individual client, couple, or family. 

The purpose of these notes is to keep an accurate road map for each client, containing:

• Assessment data
• Treatment plans and interventions
• Clinical observations and diagnoses 
• Progress notes
• Administrative data 
• Measure data
• Safety information 

How to write therapy notes

Therapists running their own private practices are busy. They may spend most of their working hours seeing clients. By the end of the day, they can be tired and most likely have a long list of other pressing tasks. 

Writing notes is likely the last thing we feel like doing. That’s why it’s important to have an efficient practice when it comes to documentation. When understand how to write therapy notes and develop an efficient note-taking practice, it will save time and feel less arduous.

Whether you’re writing therapy progress notes or documenting a biopsychosocial assessment and treatment plan you can save time by using standardized and electronic formats.

These types of therapist session notes provide a framework with cognitive prompts about what type of information to include.

SOAP notes

The SOAP notes framework includes information in the following format:

• Subjective data records the client’s perspective about their presenting problem, symptoms, and relevant history.
  
• Objective data observed by the clinician, such as mental status exam, relevant medical records from other providers, and vital signs.
  
• Assessment: the clinician’s assessment based on the subjective and objective information, and other relevant sources.
  
• Plan: information includes next steps in treatment, referrals, interventions, and resources.

DAP notes

DAP notes are a popular note style, containing a summary of information in the following format:

• Data: reason for visit, MSE information, client report of symptoms and other information since the last session, interventions, and client’s response to interventions
  
• Assessment: the therapist’s assessment of progress in relation to treatment goals, response to interventions, change in diagnosis and treatment plan/goals
  
• Plan: when the next session is scheduled, any relevant referrals made, resources provided, and any homework or next steps before the next session. 

BIRP notes 

BIRP notes can be used in a narrative or checklist format, with information organized in the following sections:

• Behavior: observations and client information about their progress since the last session, symptoms, behavior in session, and clinician assessment of their motivation, orientation, and appearance. This section can also include client quotes.
  
• Intervention: modalities and interventions the clinician has used as part of treatment and how they relate to the diagnosis and treatment goals.
  
• Response: the clinician’s assessment of how the client has responded to interventions, their effectiveness, and how they have impacted behavior. This section should include any unsuccessful interventions and steps the therapist has taken if the relationship was impacted. 
  
• Plan: Date and time of the next session, referrals, homework, resources, and consultations.

Key info to include in any type of therapy notes

Some of these note formats are included in electronic health record systems (EHR), saving you additional time. Many EHRs include pre-loaded checkboxes, fillable templates, diagnosis information and codes, and treatment planners like Wiley. 

Whichever note format you decide to follow, when writing a therapy note, you’ll want to include the following important information:

• Session information: clinician’s name, qualifications, date of encounter, start and end time, CPT code (if billing insurance), location of provider and client (ensuring both the clinician and client are in a private room and cannot be overheard), type of visit (intake, assessment, treatment session, etc.), and focus of session.
  
• Assessment information: in the first or first two sessions this section records presenting problem, symptoms, description of the symptoms or problem in the clients own words, social, psychological, and medical history, stressors and challenges, protective factors, demographic and identifying information (name, gender identity and pronouns, sexual identity (if they feel comfortable disclosing), and safety screening data.
  
• Treatment plan: including goals, objectives, interventions, duration, and frequency of sessions
  
• Clinical observations and diagnoses: such as mental status exam, diagnosis and relevant ICD-10 codes, and clinical justification for those diagnosis, such as presenting symptoms and supporting information.
  
• Progress and thematic information: a record of client reports and clinical observations with any themes developing, response to interventions, changes in diagnosis and treatment goals, and any interventions which were unsuccessful.
  
• Administrative data: any relevant administrative information, like referrals, documents completed in session, paperwork that needs to be completed.
  
• Measure records: therapists might administer a regular assessment, like a PHQ-9, or GAD 7 which can also be used to record progress.
  
• Safety information: this might include suicide screening, safety plans, and safety-specific referrals made.
  
• Plan: date and time of next session, follow up actions, referrals, and resources provided. 

Clients questions about notes in therapy

When they see us tapping away on the computer, or scribbling notes in session, clients may ask “do therapists take notes?” They may be wondering what you’re writing down. 

Some clinicians take notes while in the midst of therapy sessions with clients. They may be taking a note about something said during the conversation, recording a detail about the client’s progress, listing important action items, and other pertinent information to the client’s case. 

These therapist session notes could also be a psychotherapy note, which has clinical notes, questions, hypotheses, and items to further explore with a client. 

Some therapists make handwritten psychotherapy notes or use their electronic health record. Whichever way they are captured in stored, psychotherapy notes are private and confidential and remain separate from the official client record.

You may also experience clients taking therapy notes during therapy session., They may be capturing details they want to remember, like a diagnosis, a new coping strategy, or exercises to practice in between sessions. 

If a client appears to be overwhelmed or struggling to retain important information, you may offer to grab them a pen and paper or have notebooks and pens next to client seating areas.

7 tips for writing better therapy notes

1. Make a note of progress information, interventions, and other key information in the session. You can hand write the note, make in-session notes on the computer, or make a note in-between clients.
   
2. Write clear and concise notes, only recording brief, relevant information.
   
3. Use a note format, like SOAP, DAP, or BIRP.
   
4. Be mindful that while protected under HIPAA, clients, insurance providers, and potential litigators may request these records. Thus, be brief, strengths-based, focus on progress and process rather than a long narrative description of the session, and only record essential information.
   
5. Avoid added information about other people, like “Sarah mentioned her father had MDD.” Instead you could note, “client reported a close family member with a hx of MDD.”
   
6. Keep notes secure at all times, locking your computer, and storing notepads in a locked cabinet.
   
7. Use an EHR for therapy notes, which have pre-filled templates and checkboxes to save time.

How SimplePractice streamlines running your practice

SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.

If you’ve been considering switching to an EHR system, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.

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