A Therapist's Cheat Sheet to Writing Therapy Notes: Examples, Templates, and Best Practices

In Brief

Therapy notes play a vital role in tracking progress, refining treatment plans, and ensuring continuity of care. Yet, with so many responsibilities competing for your attention, it’s understandable if note-taking sometimes feels like just another task to complete.

However, dedicating time to write clear, comprehensive notes can significantly enhance the quality of care you provide. Well-written notes not only help you recall essential details but also offer protection for you should any legal issues arise in the future, demonstrate to clients that you are fully engaged and invested in their progress, and serve as a record of treatment for future or adjunctive providers to learn from.

In this article, we'll explore the importance of therapy notes, discuss different note-taking strategies, and provide tips for creating notes that enhance your practice and improve client outcomes.

The Importance of Therapy Notes

Therapy notes serve several critical purposes:

They document a client's symptoms, progress, and treatment to ensure continuity of care
They provide a record for legal, billing, and insurance purposes
They allow therapists to reflect on sessions and inform future treatment plans
They facilitate communication and collaboration with a client's other providers

Writing therapy notes involves meeting HIPAA-compliant standards. Notes must be securely stored, whether physically (in locked cabinets) or digitally (encrypted, password-protected).

Confidentiality tips: Only include clinical relevant information in the note and avoid mentioning sensitive client details.

Writing clear, concise therapy notes is more than just a routine task—it’s a cornerstone of effective practice. Detailed, well-organized notes allow you to track key information between sessions, helping you stay attuned to your client’s progress and any emerging patterns. They also prevent you from revisiting approaches that haven’t worked in the past, saving time and ensuring a more tailored, thoughtful approach to treatment. Additionally, thorough notes demonstrate to your clients that you’re fully present and actively engaged in their care, which can enhance trust and rapport. Whether you’re drafting progress notes to document a session or psychotherapy notes for your own reflections, developing strong note-writing skills can lead to better outcomes, greater efficiency, and a more seamless workflow in your practice.

Understanding Different Types of Therapy Notes

There are two main categories of therapy notes:

Progress Notes - These are formal records that document a client's clinical status, medical necessity, session themes, interventions used, the client response to the intervention, progress toward treatment goals, and plans for future sessions. Progress notes become part of the official client record and may be shared with other providers or requested by insurance companies. They should be written in objective, professional language.
Psychotherapy/Process Notes - These are more detailed, private notes a therapist keeps to record their impressions, hypotheses, and specific details they want to remember from a session. Process notes are generally not shared with others as they are intended as a memory aid and reflection tool for the therapist. They can be less structured and written in more informal language.

Example Snippets from Notes

Progress Note: “Client expressed insight into the relationship between recently improved sleep and beginning meditation practice for 10 minutes per night.”
Psychotherapy Note: “Client progress - improved sleep. Shows signs of ambivalence toward change (inconsistent engagement in session discussions, still in touch with ex)

The key differences between progress notes and psychotherapy notes are:

Purpose: Progress notes track the client's overall treatment and are part of the official medical record. Psychotherapy notes are for the therapist's personal use to aid in treatment.
Content: Progress notes include diagnosis, interventions, medical necessity, progress towards the goal, and plans for future sessions. Psychotherapy notes contain the therapist's impressions, hypotheses, and session details.
Format: Progress notes often follow structured formats like SOAP or DAP. Psychotherapy notes are written informally and have no required format.
Privacy: Progress notes can be accessed by the client and shared for healthcare purposes. Psychotherapy notes have special HIPAA protections and require specific authorization for release.

Best Practices for Writing Effective Therapy Notes

Writing therapy notes that are clear and concise ensures they remain useful over time. Include only essential details, avoid jargon or excessive abbreviations, and write in an objective tone.

Be specific and concise: Clearly document key information without overloading your notes. Aim for brevity while still capturing critical details.some text
- Clear: "Client expressed concern over frequent arguments with their partner and showed signs of emotional distress (tears, lowered voice)."
- Unclear: "Client was upset today about things in their relationship."
Use professional language: Write in a formal, objective style, especially for progress notes. Support your observations with concrete examples.
Prioritize timeliness: Complete your therapy notes promptly after sessions to increase accuracy. Set aside dedicated admin time to stay on top of documentation.
Be selective: Focus on documenting essential themes, interventions, and plans rather than trying to capture every detail.
Follow proper protocols: When making corrections to official progress notes, adhere to established procedures to maintain the integrity of the record.
Ensure security and compliance: Utilize secure, HIPAA-compliant software for writing and storing therapy notes to protect client privacy.
Develop a consistent system: Find a template or format that works well for your needs and stick with it. Consistency enhances clarity and efficiency.

Popular Therapy Note Templates with Examples

Some widely used note-taking templates include:

1. SOAP Notes

Subjective: Client’s self-reported reasons for seeking therapy, current symptoms, emotional state, client report of progress towards goal, and personal history.
Objective: Observations made during the session (client’s appearance, mood, demeanor).
Assessment: Therapist’s impressions of the client's mental health and engagement or response to treatment., Highlight strengths and areas for growth.
Plan:Proposed plan for future sessions, including the frequency of sessions and areas of focus and goals for therapy,

‍Example

Subjective: Client’s verbalized symptoms, functional impairments, concerns, and progress toward the treatment goal. (e.g., “I feel exhausted and can’t sleep. I haven’t made any progress on my goal of cutting down drinking. It helps me fall asleep, but then I wake up two hours later, and my mind starts racing.”)
Objective: Observable behaviors (e.g., “Client appeared fatigued, with dark circles under eyes. The client actively engaged in session discussion.”)
Assessment: Therapist’s clinical impression (e.g., “Therapist utilized psychoeducation to support the client in understanding the relationship between alcohol use and poor sleep. Therapist facilitated discussion on the Stages of Change model to support the client in exploring their level of motivation for reducing drinking. The client expressed understanding following psychoeducation, although remains unable to commit to decreasing alcohol use.”)
Plan: Next steps (e.g., “Introduce relaxation techniques to improve sleep hygiene in next session. ”)

2. BIRP Notes

Behavior: Client’s feedback on how they are feeling and behaving since the last session, challenges faced, and changes in symptoms. Therapist’s observations of client’s behavior and mood.Reports on client progress toward their treatment goal.
Intervention: The therapeutic interventions used, including strategies discussed or practiced in session.
Response: Client’s response to the interventions, including any progress or challenges encountered.
Plan: Adjustments to the treatment plan, new goals, or additional strategies to address ongoing issues in future sessions.

‍Example

Behavior: “Client avoided eye contact, appeared to be fidgeting throughout session, and described feelings of worthlessness. The client reported no progress in decreasing irritability towards their parents, who are divorcing”
Intervention: “Therapist validated client’s emotions and explored sources of self-doubt. Utilized ACT acceptance interventions to support client in increasing tolerance and acceptance of difficult emotions and experiences.”
Response: “Client engaged more actively as the session progressed. The client expressed insight into internal barriers to sitting with uncomfortable thoughts and feelings. Was receptive to the therapist's feedback and psychoeducation.”
Plan: “Assign homework to track positive affirmations.”

3. DAP Notes

Data: The client’s emotional state, presenting crisis, progress toward the treatment goal, and immediate concerns.
Assessment: Therapist’s evaluation of the situation, including any risk of harm and the severity of distress.
Plan: The intervention strategies used, including safety planning, referrals, and follow-up steps.

Example

Data: “Client reported frequent panic attacks triggered by social situations. Reported no progress towards treatment goal of engaging in social activities”
Assessment: “The client’s symptoms remain heightened despite reported use of meditation, exercise, and other coping skills outside of session and decreasing caffeine intake. Therapist provided psychoeducation on the desensitization process to begin next session.”
Plan: “Facilitate exposure techniques for anxiety management in next session. Refer to evaluation for medication management.”

Which Therapy Note Template Is Right for You?

Consider factors such as your therapeutic approach, setting, and personal preferences when choosing a therapy note template. SOAP notes are commonly used across healthcare settings, while BIRP and DAP formats may be preferred by mental health professionals in settings where behavior-focused or shorter notes are more beneficial. Experiment with different templates to find the one that best supports your clinical practice and helps you efficiently document therapy notes.

Tips to Save Time While Writing Therapy Notes

Simplifying your therapy note-taking process is key to staying efficient and avoiding burnout. Using digital tools, note templates, and proven strategies can help you write clear, thorough notes faster, so you can spend more time focusing on your clients.

Embrace technology: Explore AI-powered solutions that automate note-taking, are already HIPAA-compliant, and save you valuable time. Look for practice management software with built-in therapy note templates and intuitive interfaces.
Customize templates: Although each individual service requires a unique note, tailored, pre-formatted templates built to suit your practice’s unique needs can save time while keeping pre-written sentence fragments for frequently used interventions, phrases, and descriptors can make for quick integration into your notes.
Be concise and objective: Avoid vague language or overly emotional phrasing that can undermine the clarity and professionalism of your therapy notes.some text
- Instead of: "Client is difficult to work with"
- Try: "Client exhibits avoidance to discussing certain topics"
Develop a consistent structure: Establish a standardized format for your therapy notes to ensure all essential information is captured efficiently. This may include sections like subjective reports, objective observations, assessments, and treatment plans.
Optimize your environment: Create a dedicated workspace for writing therapy notes, minimizing distractions, and optimizing focus. Consider techniques like the Pomodoro method or background music to enhance concentration and productivity.

Examples of Therapy Notes for Different Situations

Therapy notes are essential for documenting client interactions, tracking progress, and informing future treatment plans. Here are some examples of therapy notes tailored to various clinical scenarios:

Example 1: Initial Client Session Notes

Format: SOAP Notes
Subjective: "Client reports feeling overwhelmed with anxiety and depression due to work stress and recent family issues. Describes difficulty sleeping, loss of appetite, and a sense of being 'stuck.'"
Objective: "Client appeared anxious during the session, fidgeting and maintaining minimal eye contact. Speech was coherent, though slightly slowed."
Assessment: "The client appears and reports to be struggling with symptoms of anxiety and depression. Stated they remember experiencing depression and anxiety during teen years, but this is their first time in therapy. . Client seems motivated to engage in therapy and may benefit from CBT techniques to address negative thinking patterns."
Plan: "Introduce CBT techniques next session, focusing on thought reframing. Establish short-term goals for managing anxiety and improving sleep hygiene. Schedule weekly sessions."

Example 2: Ongoing Session Progress Notes

Format: BIRP Notes
Behavior: "Client reports feeling slightly less anxious and more in control of emotions at work. Continues to struggle with negative self-talk and doubts about abilities. Reported some improvement in progress toward the goal of task completion to meet work deadlines. Appeared more engaged, making better eye contact and speaking at a normal pace than previous sessions. Affect more appropriate, though still somewhat tense."
Intervention: "Reviewed cognitive-behavioral strategies for addressing negative self-talk, focusing on identifying and challenging distortions about work performance. Introduced self-compassion exercises to address self-esteem issues. Discussed the importance of practicing thought reframing outside of sessions."
Response: "Client receptive to cognitive-behavioral techniques and engaged in self-compassion exercises. Acknowledged negative self-talk still arises about ability to complete tasks but feels more empowered to challenge those thoughts. Expressed optimism about the upcoming week. Discussed plans for self-care activities to engage in during the week."
Plan: "Focus on deepening practice of cognitive restructuring and self-compassion next session. Continue monitoring anxiety levels and consider introducing mindfulness techniques if needed. Reassess progress in 4 weeks and adjust treatment plan accordingly."

Example 3: Crisis Intervention Notes

Format: DAP Notes
Data: "Client presented in severe emotional distress following sudden family crisis. Reported feeling overwhelmed, with recurring thoughts of self-harm. Mentioned past history of self-harm but denied current intent or plan. Visibly agitated, tearful, and had difficulty focusing."
Assessment: "Client experiencing acute emotional distress, exhibiting signs of panic. Therapist completed a risk assessment. No immediate self-harm risk identified, but significant concern for emotional state. Immediate safety concerns addressed. The client agreed to the safety plan, acknowledging the need for support during the crisis."
Plan: "Provide immediate support through grounding and crisis intervention techniques to stabilize client. Establish a safety plan with emergency contacts, coping strategies, and crisis hotline instructions. Therapist will follow up the next day to reassess emotional state and ensure continued safety. Consider additional referrals if distress persists."

Frequently Asked Questions (FAQ)

How long should a therapy note be?

Progress notes should be concise - typically just a paragraph or two covering the key facts. Process notes can be longer but still focused on essential details rather than a verbatim transcript.

Do I have to write notes after every session?

Yes, it's important to document every encounter with a client to maintain a thorough record. Therapy notes don't have to be extensive, but they should capture the main themes and treatment data.

How do I balance taking notes with staying engaged in session?

Avoid getting caught up in note-taking during sessions. Jot down brief bullet points or keywords that you can flesh out later. Stay focused on being present with the client.

What should I leave out of therapy notes?

Avoid editorializing, speculation, or inserting your personal feelings into notes. Stick to facts and observations. Exclude sensitive information not relevant to treatment.

Can clients access their therapy notes?

Progress notes: Clients generally have the right to access these as part of their medical record.
Psychotherapy notes: Clients usually do not have access rights, but some states may require disclosure if requested. Therapists need written authorization to share these notes.

How do I ensure my therapy notes are HIPAA-compliant?

Both progress notes and psychotherapy notes must adhere to HIPAA regulations. Digital notes should be securely stored and encrypted. Psychotherapy notes must be kept separate from the rest of the client's file. Therapy notes are considered private health information and may not be shared with anyone without a subpoena or expressed written permission from the client.

Final Thoughts on Writing Therapy Notes

Effective therapy notes are a critical component of providing high-quality mental health care. They serve as a roadmap for tracking client progress, informing treatment decisions, and ensuring continuity of care. Investing time in developing a consistent, efficient note-taking system can significantly enhance your clinical skills and improve client outcomes.

Prioritize accuracy and professionalism: Maintain objective, clear, and concise documentation that adheres to legal and ethical standards.
Embrace technology: Utilize secure, HIPAA-compliant practice management software with intuitive therapy note templates to streamline your workflow.
Develop a consistent structure: Establish a standardized format for your notes, such as SOAP or BIRP, to ensure all essential information is captured efficiently.
Focus on key details: Prioritize documenting crucial elements like subjective reports, objective observations, assessments, progress toward treatment goals, and treatment plans.
Invest in your growth: Continually refine your note-taking skills through ongoing education, peer collaboration, and self-reflection.

Writing thoughtful therapy notes is more than a task—it’s an opportunity to track progress, guide treatment, and ensure the best outcomes for your clients. Clear, effective documentation strengthens your practice and supports clients on their path to growth and healing.