Robust EHR for Behavioral Health Professionals: 866-847-3590

How to Create a Psychotherapy Note

Everyone involved in a psychotherapy practice understands the importance of a well-written progress note. While the documentation process can prove to be tedious and boring, these notes become the backbone of any treatment plan. They also help to protect therapists from any legal or ethical backlash and to show compliance with federal, state and insurance regulations. Needless to say, there is no room for cutting corners here.

Cover the Basics

A good psychotherapy progress note must begin with a very detailed outline of “who, what and when.” Here are some good examples for each of these:

  • Who — What is your client’s age, race, sex, relationship status and work history? A solid background here can provide insight during the evaluation phase.
  • What — What is your client’s primary complaint? What are the symptoms they, or you, are associating with this complaint? When recording these notes, let the client’s words take precedence here. You can certainly create an efficient summary of them, but there is much to learn from later analysis of their word choice. It can hold valuable clues.
  • When — At what point did this complaint begin, and when did the various symptoms start to present themselves? If a medication was prescribed to address the symptoms, at what point did the medication become an element of treatment? This section will also cover a running timeline of client appointments, clinic recommendations for therapy, and exact times that intervention was recommended. Not only will this make for extremely accurate recall for later evaluation, but it will serve to protect you in case any legal issues arise.

Include the Essentials

In addition to the basics, make sure your psychotherapy notes are comprehensive, covering all aspects of treatment. What you provide here doesn’t need to go into great detail, as your personal notes can contain the bulk of your thoughts, but they do need to be clear enough for anyone else to easily understand the status and progress of your client’s treatment. Essentials will include:

  • Any prescribed medication and monitoring
  • Results of all clinical tests
  • Types of treatment utilized, as well as their frequency
  • A summary of your diagnosis, symptoms, prognosis, functional status and progress in treatment

Clarity Is Paramount

Avoiding ambiguity or any unnecessary glossing over of treatment is imperative, especially if sharing these notes. Record details of treatment and your assessments to protect you by justifying every decision you make about a client. A well-rounded description of an issue is much more valuable than the issue itself — instead of just saying a client is angry, clarify by specifying they’re prone to outbursts, crying or feeling helpless due to a certain situation.

Also, make sure you avoid language that could be taken as judgmental. Your psychotherapy notes should not be viewed as biased toward any client and should only contain your professional, in-depth analysis of their concerns.

Good note taking in any psychotherapy practice provides a means for communication, a reliable record for future reference and can serve as a shield if legal matters arise. Each of these is invaluable for sustaining your practice, so when it comes to your notes, there are no shortcuts.

Creating Psychotherapy Notes with the ICANotes Behavioral Health EHR

Using EHR software can help you write psychotherapy notes effortlessly and efficiently. The ICANotes Behavioral Health EHR includes detailed content templates to eliminate the need for clinicians to type these notes manually. View our sample therapy notes page to see examples of initial assessments, progress notes, treatment plans, and discharge summaries, or contact our team at 866-847-3590 to learn more.

Leave a Comment

You must be logged in to post a comment.