I get it. Writing session notes isn’t your favorite part of your job.

But what if you could learn to do them quickly and with confidence?

Maybe you can – with a little practice.

Many people who took my recorded progress note training are asking me to offer more opportunities to practice transforming “crummy session notes” into improved notes.

So, in this article, I’m going to:

• show you a sample “crummy session note”
• challenge you to name 5 things wrong with that note, and
• show you a much stronger note that I’ve written for that same session

Let’s look at a sample flawed note

“60-minute session. Imani discussed her visit to her mother this weekend. Feels her mom is overly critical of the way she parents her 5-year-old daughter. Session interventions: CBT. Reflective Listening. Client Centered Therapy.”

What do you think overall? Can you find five things wrong with the note?

Five things wrong with this note

1. Missing actual therapy start and stop times. I can’t say it enough: Insurance plans often require documentation of the exact start and stop times in each session note. Without these, reimbursement may be denied, as you don’t have “proof” of the length of your session. So, documented times should vary from week to week. And remember – you CANNOT include time spent writing notes or scheduling the next session.
2. Missing symptoms. The note does not specify what symptoms the client is experiencing or seeking treatment for. It’s important to document how the presenting issue (e.g., criticism from mother) affects the client’s mood, self-esteem, or functioning (e.g., anger, anxiety, depression).
3. Interventions are too vague. Listing interventions is not sufficient. Notes should describe specific techniques or exercises used, and how they relate to the client’s symptoms or goals.
4. Modality and location are not documented: It’s essential to state whether the session was in-person, by phone, or via video, and – if telehealth – where the client was located. This is a compliance requirement for many payers.
5. Missing diagnosis: Every note should include the client’s diagnosis, backed up with relevant symptoms. This helps justify the medical necessity of treatment and supports billing.

Note: I’m not saying these are the only flaws with the note, but these are the main issues.

Why this matters

The bottom line is that these omissions can lead to denied insurance claims, and a loss of income for you. Finding these deficiencies could even cause auditors to do a wider and more costly audit than originally planned. Plus, these items are essential to give you protection if a complaint is filed. Improving your notes by addressing these areas will help ensure compliance, reimbursement, and clinical clarity.

Want to see an example of a better note for this session?

“Actual session start and stop time: 11:02 to 11:57 am.
Modality and location: Telehealth video session, client at home.
CPT code: 90837 – 95 Individual session.
Diagnosis: F43.23 Adjustment Disorder with Mixed Anxiety and Depression.

Topic: Imani discussed feelings of anger and low self-esteem related to her visit to her mother this weekend.

Symptoms: Client reported feeling anger during and after the visit, triggered by her mother’s criticism of the way she parents her 5-year-old daughter. This led to ct. feeling like a bad mom and inadequate caregiver, negatively impacting her self-image. Client felt depressed, and dealt with this by binge eating. Also continues to struggle with sleep issues, averaging only 5 hours a night.

Intervention: Used CBT exercise to help the client separate her views of herself as a mother from how she thinks her mother views her. Helped her see she had choice not to internalize and react to her mother’s views, since ct. doesn’t believe them to be true. Client stated she felt this exercise was a powerful tool for her.

Plan: Follow-up appointment scheduled in one week.”

But wouldn’t notes like this take too long to write?

The “crummy note” took me 1 minute to write.

The “better note” took me just 3 additional minutes to write. Definitely doable. And worth it.

Best of all, you’ll love the feeling you have after writing these notes

You know that stress you carry daily when you write incomplete, superficial notes? Spending a few more minutes on each note should make that stress start to evaporate. Plus, you may stop procrastinating (or avoiding notes altogether) once you learn to do them efficiently but quickly. And once you start capturing what really happened in your session, I bet you’ll see how these better notes help you provide better treatment. Best of all, if an insurance plan ever asks for your notes, you may actually feel calm.

Want to feel more confident about your notes? Want to see more examples of good progress notes?

Check out my recorded documentation trainings “What’s Missing From Your Charts: Writing Great Notes” and “How to Write a 10-Minute Treatment Plan.” – click here