How often should psychiatric SOAP notes be written?

They should be completed after each session or, at a minimum, within the first 24 hours after the appointment.

How long should a psychiatric SOAP note be?

Most psychiatric SOAP notes take 10 to 15 minutes to complete. With the right EHR, this can be reduced to as little as three minutes. Writing in bullet points helps capture key patient information efficiently while keeping notes clear and structured.

What's the main purpose and benefits of a SOAP note?

SOAP notes help psychiatrists and PMHNPs make medical decisions, especially in complex situations. They best summarise a patient's current feelings and emotions, helping clinicians assess risk levels, manage medication, and determine next steps.

Can I use templates for psychiatric SOAP notes?

Yes. Structured templates ensure consistency and reduce missed documentation.

What is the best EHR for psychiatrists?

The best EHR for psychiatrists is one that supports psychiatric documentation, medication management, and behavioral health workflows. Platforms designed specifically for psychiatry typically include structured note templates, mental status exam documentation, integrated ePrescribing, and tools for tracking patient outcomes. Among the available options, ICANotes is widely considered one of the best EHRs for psychiatrists because it was built specifically for behavioral health clinicians. It offers structured documentation templates, integrated ePrescribing (including EPCS for controlled substances), built-in rating scales, and practice management tools that help psychiatrists document efficiently while maintaining compliance.

Do psychiatrists need a psychiatry-specific EHR?

While psychiatrists can technically use general medical EHR systems, platforms designed specifically for behavioral health are usually a better fit. Psychiatry-focused EHR software includes structured documentation templates, mental status exam workflows, integrated rating scales, and medication management tools tailored to psychiatric care. These specialized features help clinicians complete notes more efficiently, support accurate prescribing, and streamline practice management tasks such as telehealth, scheduling, and patient communication. As a result, psychiatry-specific EHRs can reduce administrative burden and allow psychiatrists to spend more time focusing on patient care.

What are the top features psychiatrists need to consider when choosing an EHR?

Medication management and ePrescribing Multiple psychiatry note-taking templates Integrated electronic lab orders and results Telepsychiatry Billing integration Reporting and compliance tools Customizable features Custom treatment plans.

Which screening tool is most appropriate for assessing suicidal ideation in depressed patients?

While many depression scales include an item on suicidal thoughts (for example, item 9 of the PHQ-9), these questions are limited in scope. If a client endorses suicidality, it is best practice to follow up with a validated, suicide-specific tool such as the Columbia-Suicide Severity Rating Scale (C-SSRS). Depression tools can flag potential risk, but a dedicated suicide risk assessment should guide safety planning and intervention.

What are best practices for interpreting and acting on depression assessment scores?

Scores should always be interpreted within the broader clinical context. Use cutoffs as guides for severity, but combine them with interviews and collateral information to capture the whole picture. High scores should prompt timely treatment planning, potential referrals, or further evaluation. Low or improving scores can reinforce current strategies and motivate clients by showing progress. Always document not just the score, but the clinical meaning and the next steps—whether that’s adjusting therapy, monitoring more closely, involving family supports, or escalating to a higher level of care if risk is present.

Can I bill for depression screening?

Yes. Brief tools like the PHQ-9 may be billed using CPT code 96127 , depending on payer requirements.

Are these tools free to use?

PHQ-9, GDS, Zung, HAM-D, and QIDS-C are in the public domain. BDI-II requires licensing.

How do cultural and age factors affect the accuracy and choice of depression assessment tools?

Cultural background and age can influence how individuals understand and report symptoms. Some tools may emphasize somatic symptoms that overlap with medical conditions common in older adults, while others may not capture culturally specific expressions of distress. Language translations, literacy level, and cultural norms about emotional disclosure also affect accuracy. For children and adolescents, developmental stage shapes how symptoms appear and how questions are understood. Clinicians should select tools validated for the population they serve, use culturally appropriate translations when available, and always interpret scores in light of cultural and developmental context.

What are therapy notes?

Therapy notes are the clinical records that therapists, counselors, and other mental health professionals create to document client care. They include several types of documentation — progress notes, psychotherapy notes, intake assessments, treatment plans, and discharge summaries — each serving a different purpose. Progress notes are the most common type, written after each session to record the client's status, interventions used, and progress toward treatment goals.

What is the best therapy notes format?

The most widely used formats are SOAP (Subjective, Objective, Assessment, Plan), DAP (Data, Assessment, Plan), and BIRP (Behavior, Intervention, Response, Plan). There's no single best format — it depends on your clinical setting, payer requirements, and personal preference. SOAP is the most universally recognized, DAP is efficient for therapists who prefer a streamlined structure, and BIRP is strong for tracking intervention effectiveness. The most important thing is choosing one format and using it consistently.

What is objective content in therapy notes?

bjective content refers to the factual, observable information you document based on what you directly saw and heard during the session — as opposed to subjective content, which is what the client self-reports. Objective content includes observations about the client's appearance, behavior, speech, affect, eye contact, psychomotor activity, and mental status. It also includes measurable data like assessment scores. Strong objective content anchors your clinical assessment in facts rather than opinions and makes your notes more defensible.

Can I use words like "appeared" or "seemed" in my therapy notes?

Yes, but only when they're followed by specific, observable descriptions. "Client seemed anxious" is vague and unhelpful. "Client appeared anxious, as evidenced by rapid speech, fidgeting, and avoidance of eye contact" is objective because you're describing what you actually observed. The words themselves aren't the problem — the issue is using them without concrete behavioral evidence to support them.

How long should therapy notes take to write?

Most therapists should aim to complete a progress note in 5-10 minutes per session. If you're consistently spending 20-30 minutes per note, the issue is usually a lack of templates, inconsistent formatting, or trying to include too much non-essential detail. Using a behavioral health EHR with menu-driven documentation — like ICANotes — can reduce documentation time significantly. Clinicians using ICANotes report completing notes in about 5 minutes per session.

Are therapy notes considered medical records?

Progress notes, intake assessments, treatment plans, and discharge summaries are all part of the official medical record. Psychotherapy notes (also called process notes) are the exception — under HIPAA, they are stored separately from the medical record and receive additional protections. Clients generally have the right to access their medical records, including progress notes, but psychotherapy notes require separate authorization.

How should I document therapy interventions in my notes?

Name the specific modality or technique you used — for example, "cognitive restructuring (CBT)," "exposure with response prevention," "motivational interviewing," or "EMDR desensitization phase." Then briefly describe what you did and how the client responded. This demonstrates your clinical reasoning, supports medical necessity, and helps other providers understand your treatment approach. For a detailed list of intervention language, see our guide: Therapeutic Interventions for Progress Notes →

How long do I need to keep therapy notes?

Retention requirements vary by state and licensing board, but most states require you to retain therapy records for 7-10 years for adult clients. Records for minor clients typically must be kept longer — often until a specified number of years after the client turns 18. Check your state's specific requirements and develop a clear retention and destruction policy for your practice.

How can I make sure my notes will support insurance reimbursement?

Properly formatted therapy notes for insurance reimbursement should clearly demonstrate medical necessity . When writing therapy notes for insurance reimbursement, include specific symptoms and functional impairments . Document how your interventions address the diagnosis and show progress toward measurable goals. Many claims denials can be traced back to inadequate therapy notes for insurance reimbursement.

How can technology improve the accuracy and efficiency of therapy documentation?

Technology streamlines note-taking by reducing manual effort and minimizing errors. EHR systems with structured templates help therapists stay consistent and compliant, while voice-to-text tools and automation capture details quickly without slowing down session flow. Features like integrated treatment plans, auto-scored assessments, and smart prompts ensure documentation is both thorough and accurate. By leveraging these tools, clinicians can spend less time writing notes and more time focusing on client care. Pro Tip: ICANotes offers menu-driven documentation, integrated assessments , and automation features that save time and help clinicians produce accurate, professional notes with ease.

Is a separate "Informed Consent" required for EMDR?

While not always legally mandated beyond standard consent, it is clinical best practice. Document that the client was informed about the risk of "high emotional arousal" and "post-session processing." Note their agreement to use the Safe/Calm Place and their understanding that they can stop bilateral stimulation at any time.

What should the therapist say when checking the VOC during the installation phase?

During the Installation phase, the therapist asks the client to hold the target image and positive cognition together in mind, then rate how true the positive belief feels on a scale of 1 (completely false) to 7 (completely true). A typical prompt might be: "When you think of the original experience, how true do the words [positive cognition] feel to you now, on a scale of 1 to 7?" The therapist repeats this check after each set of bilateral stimulation until the client reaches a VOC of 7.

How do you explain EMDR to clients?

When preparing clients for EMDR, explain that it's a structured therapy designed to help the brain process distressing memories so they no longer trigger strong emotional or physical reactions. You might say something like: "During EMDR, I'll ask you to briefly focus on a difficult memory while following my finger with your eyes. This bilateral stimulation helps your brain reprocess the memory so it becomes less distressing over time." Emphasize that they won't need to describe the event in detail, which often puts anxious clients at ease.

What is assessed during EMDR Phase 1 history taking?

During Phase 1, the clinician gathers the client's history across three time frames: past disturbing memories, present-day triggers and symptoms, and future goals. The therapist identifies target memories, maps them on a timeline, explores the client's negative and positive self-beliefs related to those experiences, and determines which target to address first in treatment. This phase typically takes one to two sessions.

What three things should the clinician ask the client to notice when beginning desensitization?

When starting the desensitization phase, the clinician asks the client to hold three things in mind simultaneously: the target image associated with the disturbing memory, the negative cognition (their negative self-belief about the experience), and any body sensations they notice while focusing on the image and belief. The client maintains awareness of all three while performing bilateral stimulation.

How long does EMDR therapy take?

EMDR is a short-term therapy. Sessions typically occur once or twice a week and run about 90 minutes each — longer than the standard 45-minute therapy session. Most clients complete treatment in six to 12 sessions, though some may benefit from fewer. The total length depends on the complexity of the client's history and the number of target memories identified during Phase 1.

What's the difference between SUD and VOC in EMDR?

SUD (Subjective Units of Disturbance) measures how distressing a target memory feels to the client on a scale of 0 to 10, where 0 is no disturbance and 10 is the worst imaginable. VOC (Validity of Cognition) measures how true the client's positive self-belief feels on a scale of 1 to 7, where 1 is completely false and 7 is completely true. During treatment, the goal is to bring SUD down to 0 and VOC up to 7. Clinicians track both ratings across sessions to measure processing progress.

What does a completed EMDR session look like?

A fully completed EMDR processing session ends with the client achieving a SUD of 0, a VOC of 7, and a clean body scan — meaning they can hold the target memory and positive cognition in mind without noticing any residual distress or tension in their body. The therapist then conducts a debriefing, letting the client know they may continue processing after the session and encouraging them to note any thoughts, feelings, or dreams that arise. See the EMDR progress note examples above for detailed documentation of both in-progress and completed sessions.

How do I document "Looping" or "Processing Blocks" in Phase 4?

When a client stays stuck at a high SUD, document the specific "interweave" used (e.g., cognitive, imaginative). Note the shift from "processing" to "active intervention." This demonstrates medical necessity by showing the clinician’s active role in moving the client past a neurological stalemate rather than just passive observation.

How should I document "Atypical" Bilateral Stimulation (BLS)?

If using tactile buzzers, tapping, or audio tones instead of eye movements, document the specific modality and the clinical reason for the choice (e.g., "visual fatigue" or "client preference"). Consistently recording the type of BLS used ensures continuity of care if the client transitions to another provider.