Good patient notes are essential for providing high-quality care to your clients because they help maintain continuity of care. As a therapist, you’re likely to see a lot of different clients with various experiences and needs in a single day. You’ll rely on your patient notes to differentiate between clients and prevent important information from being lost or forgotten.
This post discusses how to write patient notes, reviews common mistakes, outlines what you should include, and it reviews how you can make the most of the therapy notes you take.
Writing Helpful Patient Notes
Progress notes are a key component of counseling sessions. These notes document the client’s progress toward their treatment goals and serve as a record of the therapy sessions. You should write progress notes after each therapy session and include a summary of the session, any interventions or techniques used, the client’s response to those techniques, and any changes to the treatment plan.
Three main aspects to writing helpful progress notes:
- Observing – The first step in writing progress notes is observing your client and noting these observations. As well as listening to what they say, you should pay attention to your client’s nonverbal communication, such as body language, facial expressions, and tone of voice. Noting these nonverbal cues gives you a clearer picture of your client’s overall well-being in each session.
- Understanding – Next, you need to understand the client’s perspective. Use empathy and active listening skills to help you acknowledge your client’s point of view. This stage also involves considering the patient’s presenting problems, medical history, and relevant cultural or social factors that may impact them.
- Reflecting – Finally, you should reflect on the client’s progress. Look at what treatment approaches worked well for them and what didn’t. This reflection can help guide your treatment plan for the client and help you determine what steps to take going forward.
Incorporating the above three techniques in how you write patient notes will ensure that your notes are extensive and accurate, allowing for the best care for your clients.
Three Types of Therapy Patient Notes
Progress notes aren’t the only documentation you need. You also need to be able to write notes for when you meet a new client and when you discharge them from your care. Writing all types of patient notes is critical to ensure you comply with all regulations and provide the best possible care for your clients.
Three main types of therapy patient notes you may need to write are:
- Initial Evaluation Notes – These are the notes you write up after meeting a client for the first time. You detail the client’s background, mental health history, and current symptoms in these notes.
- Progress Notes – These are the notes you make after each session. They detail how the session went, including a summary of what was covered, any treatments you tried, and how the client responded. You’ll also want to document any changes you make to the treatment plan.
- Termination Notes – When you’ve finished or ended the treatment of a client, you’ll also need to write termination notes. Don’t assume you’ll remember how things ended or why you or the client discontinued treatment. These notes typically summarize the client’s issues, progress toward their treatment goals, significant events during treatment, and recommendations for follow-up care. If you ended their treatment for a particular reason, you also want to include it in these notes. The client may want to re-establish care, so these notes can guide your decision-making if that happens.
This post focuses on progress notes, but you can and probably should apply most of the suggestions to all notes.
Benefits of Effective Therapy Patient Notes
Effective therapy patient notes aren’t just essential to help you recall where you are with each client. They have other benefits too.
Benefits of effective client notes include:
- Assists in Legal Compliance – Most states have a law mandating that therapists maintain accurate and complete patient notes. These notes serve as a legal record of the treatment provided to a patient. They may be used in court proceedings or the event of an audit or investigation. There are also ethical guidelines concerning note-taking that therapists must follow. By having effective therapy patient notes, you can ensure you’re adhering to all guidelines and regulations.
- Enhances Patient Care – Good patient notes can help improve the quality of care you provide your clients. It’s unrealistic to think you’ll remember everything about every client. Your notes equip you with an easy way to track the client’s progress, record treatment interventions, and evaluate the effectiveness of the current treatment plan. They can help guide future sessions and allow you to track what’s working and what needs changing. This overview of treatment allows you space to make adjustments where necessary and recognize trends in a client’s responses to treatment or their concerns.
- Facilitates Client Engagement – Clients are more likely to become active participants in their care and treatment when they feel empowered and part of the decision-making process. By maintaining effective therapy patient notes, you can help to engage your client by inquiring specifically about things you discussed in previous sessions or noting trends in their experiences to discuss with them.
Things to Include in Patient Progress Notes
Progress notes are not the same as psychotherapy notes.
Psychotherapy notes are detailed, confidential notes where you include your observations, impressions, and interpretations of the client’s behavior. These notes also include insights or questions that arise during the session. They are your private files.
Progress notes are brief, objective, and factual. They typically include only information about the client’s symptoms, progress, and treatment plan. They are more of a summary your client can request access to and are part of their official medical records. They may be subject to subpoena and may be read in court. This possibility means that you should be mindful of what you must include in these notes and what isn’t truly necessary.
There are some mental health practitioners who choose to keep two sets of notes. One that serve as the official record and a second set for private use. The notes for private use still must maintain the same security and confidentiality rules, but would not be subject to subpoena.
Things to include in client progress notes:
- General Observations – These can include the client’s mood, appearance, or behavior during the session. You can better understand patterns across the sessions by tracking these and any nonverbal cues.
- Patient Engagement – You should also note the client’s level of engagement throughout the session, such as their participation in the conversation or activities.
- Patient History – Include an overview of your client’s medical and mental health history, including any relevant past treatments.
- Patient Goals and Progress – Summarize your client’s treatment goals and any progress they have made toward achieving them since the last session.
- Clinical Impressions and Diagnosis – Depending on where you are with the treatment, you should include any clinical impressions and diagnoses in the notes.
- Treatment Strategies – Summarize any strategies you tried with your client, from types of therapy to specific tools you used with them.
- Relevant Information – Anything that may impact your client’s mental health or treatment, such as new stressors or changes at work or home, should be included in the progress notes.
Including all the above information ensures that your client notes are comprehensive and useful.
Common Note-Taking Mistakes to Avoid
Your client care may only be as good as your notes, so you want to make sure they’re comprehensive enough and accurate.
Here are some very common note-taking mistakes you should avoid:
- Not Taking Notes in Real Time – You may think you’ll take quick notes after a session and remember what you want to document, but the best-laid plans don’t always come to fruition. If you try this approach, you may get pulled in another direction and need to return to your notes much later. It’s easy to forget or misremember things if you don’t note them as they happen. It’s best to capture meaningful, accurate information during the session.
- Disorganization – It’s best to have a standard approach for taking notes, including whether you write them or document them electronically. It’s also a good idea to store them systematically, whether in a filing cabinet or electronically. Having client notes scattered here and there in various formats makes you more likely to lose them or forget something.
- Failing to Capture Essential Details – Missing essential details such as medical history, medications, allergies, or symptoms can lead to incomplete or ineffective treatment. In the worst case, it could lead to negligence.
- Lack of Clarity – Make sure your notes are concise, explicit, and specific. Use accurate medical terms and avoid ambiguous language. Vague or unclear notes can lead to confusion and misunderstandings and negatively impact client care. Make sure, instead of simply writing that your client is experiencing depression, for example, that you write exactly what symptoms the client is experiencing that led you to that conclusion.
- Legibility Problems – Your notes need to be easily accessible to everyone involved in the care of your client. Just because you can read your handwriting doesn’t mean everyone else can. Either write neatly or take the time to type up the notes. This tip also applies to the formatting of your notes. Ensure that your format is neat and consistent to avoid any confusion.
- Omitting Review – If you don’t review your notes regularly, you’ll likely miss out on noticing patterns or themes in your client’s treatment and responses. You may miss the opportunity to amend or adjust treatment methods or notice when something isn’t working for a particular client. In the worst case, you may miss a clue that would help you better treat a client or avoid a crisis.
By avoiding the above common mistakes in note-taking, you can be sure that your notes are as high quality as possible and are effective in helping you and other healthcare professionals treat your client.
Tips for Writing Quality Therapy Notes
You may have your own way of writing therapy notes, which is fine if the method works for you. But, if you want to improve your notes, there are ways to do so.
Useful tips for writing therapy notes include:
- Use a Standardized Format – Each therapist and practice may have its own format and style for taking patient notes. However, adhering to a standardized format across all patient notes is best. Having one format means that the notes will be organized and easy to access when needed.
- Write Concisely – While you want to make sure your notes cover everything important, you also want to write concisely. Using clear and concise language leaves no room for personal interpretation, meaning anyone involved in your client’s care can read and understand them exactly how they were meant.
- Use Correct Language and Abbreviations – It may be tempting to use shorthand and slang to make the notes quicker to write, but remember that other people can view some of them. Again, correct language and accurate abbreviations mean there is no room for ambiguity. Anyone who reads your notes should be able to understand them.
- Include Actionable Information – Include actionable information in your notes to see your client’s progress from session to session. This information may include specific goals or objectives for the client to work toward and any recommendations for homework or follow-up care.
- Incorporate Client Feedback – Be sure to note if your client has strong opinions regarding their treatment. This feedback ensures that your client’s perspective is considered in the treatment process, helping to improve treatment outcomes and the therapist-client relationship.
- Focus on Outcomes – To track the effectiveness of the treatment and guide future sessions, make the outcomes of each session the main focus of your notes. This focus means including details like any progress toward treatment goals and any changes to the treatment plan.
- Adhere to Confidentiality Guidelines – Follow confidentiality guidelines when taking therapy notes to protect the client’s privacy. Also, where possible, don’t use the names of friends or relatives in notes that others could read.
- Check for Errors – Before you finish your notes, read through them one last time to check for accuracy. Confirm any diagnoses or medication dosages before finalizing. Also, make sure the notes are complete and you didn’t omit anything important before considering them final.
Learning to write effective client notes quickly and easily means that you can focus your energy on treating your clients.
Patient Notes Template Examples
Some clinicians may use a template for their progress notes, like the options below.
Behavior, Intervention, Response, Plan (BIRP):
- Behavior – Describe the client’s behavior during the session, including body language and other nonverbal cues.
- Intervention – This section includes a recap of any interventions used during the session, such as therapeutic techniques, counseling strategies, or medication adjustments.
- Response – Note the client’s response to any interventions or adjustments, whether positive or adverse.
- Plan – Note an overview of the plan for future sessions. This plan includes amendments or adjustments going forward and any recommendations for follow-up care.
Description, Assessment, Plan (DAP):
- Description – Include any observable and measurable behaviors that describe the client during the session.
- Assessment – Assess the client’s current health based on how they are now and their history. Include clinical impressions or diagnoses in this section.
- Plan – Goals for future sessions go here. Include any changes in the therapy plan and the next steps.
Subjective, Objective, Assessment, Plan (SOAP):
- Subjective – Write a statement about any relevant client behavior or feelings. You may include direct quotes from the client here.
- Objective – This section should contain observable, quantifiable, and measurable data about the client and their behaviors. For example, if you’re treating a client for anxiety, you may note how many times they say they’re “worried about” something during your session and whether they’ve experienced any panic attacks since your last session.
- Assessment – This section involves assessing the client’s current mental health, including any diagnoses or clinical impressions.
- Plan – An overview of the plan for future sessions, including any changes to the treatment plan, goals for the next session, and recommendations for follow-up care.
Other therapists may choose to create their own templates. Ultimately it depends on your note-taking style and personal preferences.
Always include the following information in your patient notes:
- General and Identifying information – The client’s name, age, gender, contact information, and any relevant medical history.
- Client Behavior – Summarize the client’s behavior throughout the session, including their mood, speech patterns, and level of engagement.
- Short-Term Progress – Summarize your client’s progress toward their treatment goals since their last session. You may want to label goals, for example, with numbers, to make it easier to see which goals the client is working on in and between each session.
- Safety Concerns – This section includes any safety concerns related to the client’s mental or physical health, such as suicidal ideation, self-harm, or substance use. It can also contain any concerns about harm to others.
- Diagnosis and Changes to Medication – This section includes any updates to the client’s diagnosis or changes to their medication.
- Given Recommendations and Resources – Sometimes, you may provide your client with resources, such as handouts or helplines, which you want to note. You may offer the client referrals to other healthcare professionals, community resources, or self-help materials. Document the offer of help, even if the client doesn’t take you up on it.
- Client Response – Clients may not always respond positively to an intervention, but you should record their responses in your notes. This record allows you to see if there is a pattern of which interventions are less effective for the specific client and can guide you in determining the treatment plan.
- Plan of Action – You should record any changes to the treatment plan in the client notes. Note any recommendations for follow-up care and any short-term goals you and the client set.
Building Your Practice with All Counseling
Writing patient notes well is essential for all mental health professionals to provide effective client care. Whether you choose to use a template such as SOAP or use your own, as long as you’re consistent with it, you’ll be able to capture the information you need.
If you’re interested in growing your practice, All Counseling can help. By claiming your profile, you’ll help people looking for therapists just like you find your services.