Hastily written notes may have worked when you were running a smaller practice, but once your client list grows, digital tools are the key to scaling up your therapy note-taking.
If you’re looking for therapy notes templates to speed up your documentation while keeping it clear, concise, and informative, read on for our guide to some of the best.
Before you dive into this guide, why not try out Quenza’s $1 trial today for 30 days? Quenza, our therapy notes software, will help you create HIPAA-compliant online session notes easily and effectively, ultimately helping you make a bigger positive impact on your clients’ health and wellbeing.
What Are Therapy Notes? 2 Examples
Therapy notes are the observations and thoughts that a practitioner makes during their sessions with a client.
While their content will vary depending on a provider’s particular specialty (e.g. physical therapy, psychotherapy, or occupational therapy), and their particular purpose (e.g. progress notes vs. psychotherapy notes), they generally allow professionals to document what takes place in a session, for reference once an appointment is over.
2 Examples of Therapy Notes
There are two broad categories of therapy notes:
- Progress notes – Professional, clinical notes that document the progress of a patient’s treatment about the facts of a patient’s case, as well as the care and treatment they are receiving. Progress notes can be made by therapists involved in a patient’s mental health treatment, as well as by other providers involved in their general health., and
- Psychotherapy notes – These are confidential, private records of a psychotherapist’s opinions, thoughts, and feelings about a session. Also referred to as ‘private notes,’ these documents may include a practitioner’s analyses, as well as any helpful hypotheses that can inform future sessions.
Therapy notes are the observations and thoughts that a practitioner makes during their sessions with a client, about their care, progress, or condition.
Progress notes not made in a mental health context may be shared between multiple providers involved in a patient’s treatment.
They may contain important information such as a patient’s medical history, prescriptions, or past treatments, like the physical therapy notes below:
They may follow a particular structure, such as the SOAP note show above, and may not necessarily be bound by the same confidentiality laws and HIPAA regulations as psychotherapy notes.
Psychotherapy notes, in contrast, are private and often more detailed notes that may contain a psychologist’s professional thoughts, opinions, and analyses of a patient’s case and progress:
Psychotherapy notes like the generalized anxiety BIRP notes above may be written by psychiatrists, mental health counselors, or psychologists.
In digital therapy contexts, they are generally created and stored using HIPAA-compliant therapy notes software to ensure they remain secure and private.
How To Write Therapy Notes: 4 Tips
When it comes to documenting your sessions, there’s no one-size-fits-all approach to writing therapy notes.
If your goal is to create informative, helpful notes, however, there are a few best practice tips to keep in mind.
In a nutshell, therapy notes should be:
- Clear and concise – try to cut straight to the point, and include only what is relevant while backing up your notes with evidence and facts where required
- Consider your use of jargon – professional or sector-specific terms are great if you’re writing private psychotherapy notes, but try to avoid using them if your notes will be read by others
- Understand the HIPAA requirements – if you’re writing mental health notes, our guide to Writing HIPAA Compliant Psychotherapy Notes will help you adhere to privacy and security regulations, and
- Use a therapy notes template – documentation is much more efficient when you stick to a format, and frameworks such as SOAP, DAP, or BIRP can ensure you don’t forget critical elements.
3 Templates You Can Use In Your Practice
There are multiple templates that can help you structure your session or progress notes, but the three most commonly used structures in therapeutic settings are the SOAP framework, the BIRP structure, and the DAP model.
SOAP notes are widely seen in healthcare and psychotherapeutic settings and are a handy way to create structured, organized documents using four main sections:
- Subjective data on a patient’s progress or therapy, e.g. observations, thoughts, or their reported experiences
- Objective data, e.g. test results or mood sampling data
- Assessment, which integrates this subjective and objective information to offer a diagnosis, and
- Plan, which provides a detailed description of further or future actions emerging from a patient’s session.
BIRP is another therapy notes acronym used by psychologists and health providers to structure their documents.
B, I, R, and P stand for:
- Behavior – where a client’s challenge is presented using both subjective and objective data
- Intervention – which summarizes the session or therapeutic conversation, describing the treatment or methods to be employed
- Response – covering a patient’s response to the above intervention, and
- Plan – which reports the focus of the next therapy session and when it will occur.
A shorter format than SOAP and BIRP notes, DAP model therapy notes summarize:
- Data – covering objective observations from a therapy session, from a client’s behavior and affect to their responses
- Assessment – for a professional’s subjective interpretation of the objective data, and
- Plan – where a therapist uses information from the previous two sections to report their decisions and present a treatment plan.
Best Telehealth App and Software For Writing Notes
Quenza gives you everything you need to design SOAP, BIRP, DAP, and completely bespoke therapy notes templates effortlessly, then save them for use each time you have a client session.
While many therapy notes software providers offer pre-structured formats for specific frameworks, Quenza gives you the unique flexibility to design your templates in the most efficient, effective layout for your work.
With a purpose-built Activity Builder for crafting note-taking templates and a wide range of ready-to-customize examples for you to work from, Quenza is specially designed to help you create notes, save them in a HIPAA-compliant manner, and store them in organized client profiles where you can refer to them from any device.
How To Write and File Your Notes with Quenza
Quenza’s therapy notes app helps you create notes in two ways: you can craft custom templates for re-use time and again, or simple unstructured notes that are stored in each client’s file.
How To Create Custom Therapy Note Templates
If you’re ready to create clear, informative notes with Quenza, simply open up your drag-and-drop Activity Builder:
Your Activity Builder is where you can design everything from custom client exercises to your own psychotherapeutic interventions, and it’s perfect for building your own note-taking templates.
To create sections for different headers, use page breaks as we’ve done above – here, we’ve combined free text boxes with B, I, R, and P sections for our own digitalized BIRP note template.
Once you’ve saved your templates to your library, they’ll always be there for you to open up and edit. When you’re next in a therapy session, just open up a copy of your template and save your completed under a new, relevant heading.
How To Write Private Client Therapy Notes
If private, free-form, and client-specific notes are what you’re keen to create, you can do this in the “Notes” section of each Client’s personal tab:
Here, you can date each of your Client Notes in an organized way that helps you keep tabs on their progress.
A Look At Writing Group Therapy Notes
Want to create notes for your online group therapy sessions?
Just open up your therapy group and follow the same steps to create private notes for all of your participants, visible to your eyes only.
You can download your notes as PDFs, too, for a convenient hard-copy record at your practice.
7 Helpful Online Features Included In Quenza
Once you know how to create your own note templates in Quenza, you’ve already got the skills you need to create a massive range of custom therapy tools.
You can also:
- Add your practice logo to your templates and materials with the White Label feature
- Share your note templates, therapy forms, or activities with clients using Quenza’s free, multilingual client app
- Combine your psychology interventions and activities into programs, courses, pathways, or treatment plans using Quenza’s Pathway builder
- Prompt your patients to complete their activities using pre-scheduled notifications and reminders
- Stay in the loop with your clients using Quenza Chat for one-on-one or group conversations
- Deliver group therapy with up to 50 participants using the Quenza Groups, and
- Stay on top of your clients’ progress in real-time using Quenza’s live results tracking.
The array of ways to use Quenza in therapy, coaching, and counseling is incredibly wide, and therapy notes are just the beginning. If you’re keen to discover how you can elevate your impact by making the most of Quenza’s tools, you’ll find a whole bunch more inspiration in our Psychology and Counseling Tools section.
There’s no right or wrong way to create therapy notes; provided they’re clear, helpful, and informative, there’s only the way that you prefer to write.
With custom digital templates that are accessible from any connected device, you’ll always know that you’re covering all the critical elements of a session, and feel more confident in your practice.
We hope you enjoyed our guide. Don’t forget to start your $1, 30-day Quenza trial today.
With unlimited access Quenza’s therapist-friendly toolkit, you’ll have all you need to create more professional, and individualized therapy notes more efficiently, maximizing your impact and bringing your clients better outcomes.
- ^ Aghili, H., Mushlin, R. A., Williams, R. M., & Rose, J. S. (1997). Progress notes model. In Proceedings of the AMIA Annual Fall Symposium (p. 12). American Medical Informatics Association.
- ^ HHS.gov. (2017). Combined Text of All Rules. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/combined-regulation-text/index.html
- ^ Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP notes. StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/