One Tip for a Quick Session Note

Many therapists struggle with note taking.  What can you say that is different than what you wrote last week, and the week before?

So, you procrastinate.  When you finally do sit down to write the note, you stare blankly at the empty page or computer screen.  How can you briefly sum up a complex and emotional session?

Sometimes, half the battle is just getting past the blank page.

Here’s one tip: Have a format for your first sentence that you use every time.  

This can make it easier to get something down, to just get started, and to get your writer’s juices flowing.

Try using this first sentence format:

“Client reports feeling XXXX about XXXX.”  

Example:

“Client reports feeling ‘overwhelmed and constantly worried’ about her job performance.”  

It may seem simple, but this format quickly captures

1. the session topic
2. the client’s emotions (in this case, using her own words)
3. the subject of their concern

This format forces you to immediately describe the client’s emotional condition, which is the main purpose of the note.

And if a health plan were to read this sentence, they have already learned that the client is in some emotional distress, and isn’t only seeking personal growth work (which is essential since the latter would not be covered by insurance).

More examples using this format:

• “Client reports feeling unmotivated and depressed after constant rejections in job search.”
• “Client reports feeling angry about ex-wife’s harmful comments to their children.”
• “Client reports feeling sad and scared as she believes her wife is drinking again.”

A few pro tips:

• The best session note tells us something about the symptoms and status of the client’s diagnosis, so keep this in mind when writing your note
• Don’t feel obligated to document every topic discussed
• Of course, more information is needed about the session, including about the topics discussed, the client’s symptoms and functioning, and your interventions.  But sometimes just having a tool to start the note can prove helpful in overcoming writer’s block.

For more helpful tools and a great note template that will please insurance plans and licensing boards, check out my pre-recorded webinar “What’s Missing From Your Charts: Writing Great Notes.”