Guide for Crafting Therapy Records [Template Included + Illustrative Samples]

In the realm of mental health care, therapy notes play a pivotal role in delivering high-quality care, monitoring client progress, and coordinating with other providers. This article outlines the key practices for writing effective therapy notes, the various note formats, and strategies to streamline the note-taking process.

Setting a Clear Purpose

Each note should have a defined purpose, whether it's a session summary, crisis intervention, or progress tracking. This ensures the note is clinically useful and legally compliant.

Utilizing Established Formats

Three common formats for therapy notes are SOAP (Subjective, Objective, Assessment, Plan), GIRP (Goals, Intervention, Response, Plan), and Progress Notes.

SOAP captures client reports, therapist observations, clinical interpretation, and future steps, making it widely used for mental health and occupational therapy.
GIRP focuses on treatment goals, interventions used, client reactions, and next steps, and is common in physical therapy and adaptable to other fields.
Progress Notes include client observations, clinical interpretations, and treatment plans, often summarized in concise entries.

Documenting Client Presentation and Session Focus

Succinctly note the client's observable demeanor, emotional state, and topics discussed. This helps track patterns and tailor treatment.

Recording Specific Interventions and Techniques Used

Document any new coping skills or therapies introduced to support clinical care and insurance validation.

Employing Measurable, Observable Data

In the Objective sections, use measurable, observable data (e.g., client's behavior, skills, responses) rather than vague statements.

Writing Clear, Concise, and Professional Notes

Avoid personal judgments, unsupported opinions, and repetitive content. Use strength-based and patient-centered language.

Ensuring Timeliness

Complete notes within 24-72 hours after sessions for accuracy and relevance.

Maintaining Legibility and Proper Grammar

Ensure notes are legible and grammatically correct, especially if handwritten. Digital entries should follow standardized templates to ensure clarity and consistency.

Common Mistakes to Avoid

Using vague or judgmental language.
Repeating previous session information instead of updating progress and plans.
Failing to document specific interventions and client responses.
Omitting dates, session durations, or treatment goals.
Overloading notes with unnecessary detail ("note bloat").

Streamlining Therapy Note-Taking

Strategies to make note-taking more efficient include writing notes as soon as possible after every session, using shorthand or a structured therapy note template, considering voice-to-text tools or AI assistants, and keeping a library of intervention language.

Other Note Formats

BIRP notes track interventions and responses.
DAP notes combine subjective and objective data and information.
PAIP notes are useful for case management and have multiple providers on a care team.

Ethical and Legal Compliance

Therapeutic documentation should be accurate, timely, and secure at all times. Familiarize yourself with HIPAA and your state's legal standards to ensure compliance.

Reflecting the Client's Perspective

Therapy notes should reflect how a client views themselves within their own experience, not just clinically.

A New Feature: Talkcast

Talkcast, a new feature, enables therapists to create personalized content in the form of short podcast-style audio episodes for their clients.

Documenting Risks

Always document any concerns you have regarding risks.

In conclusion, therapy notes should be purposeful, formatted consistently (preferably with SOAP or GIRP), detail client behavior and therapist interventions, use objective language, and adhere to professional and legal standards to support effective clinical care and documentation integrity.