Notes Templates & Ideas for Clinical Documentation

Notes Template Ideas Rewritten for my Brain from various other Mental Health Professionals

Note: These ideas are collected from several different therapists. I am adding credit to those who provided these ideas as I gain consent from those who shared them. It takes a village!

Compliance Expectations & Requirements to Consider

  • 24-72 hours after session (depending on insurance provider)

  • 3-4 interventions for a 60 minute session (roughly 1 per 15-20 minute session)

  • What you "have" to do is pretty much based on state regulations where you practice. But a good schema for across the board acceptability of documentation is "the clinical loop."

    • 1. Diagnosis- must meet medical necessity for treatment (if insurance or county funding)- impairment in at least one major area of function (work/school; social/community; self-care)

    • 2. Treatment plan/goals should address symptoms that impair function, and should be measurable, achievable, and some evidence behind method.

    • 3. Progress note should address client presentation, progress on goal(s), interventions in session toward goals, and client's reaction. Also good is some nod to what you plan for the next session.

    • Most common note templates fulfill these things. in private practice, you only HAVE to do what your state dictates legally and ethically.

      • if you take insurance or state $$, the above requirements are generally good across the board.

      • for OON billing, it's not 100% clear what is required beyond diagnosis. Some insurance companies may require to see notes, tx plans, etc, some don't.

      • finally, in private, cash-pay practice, you may only need to do some kind of note- not even a progress note. Just a short note of the basics. You don't even need a diagnosis, if it's not going through insurance.

      • In short, if you use the basic Simple Practice treatment plan, and SOAP notes, you should be fine as long as your dx fits, the clt meets medical necessity, goals fit the diagnosis and impairment, and notes address goals.

Template 1: General Template for Compliance

  • Start Time

  • End Time

  • Mini Mental Status Exam

  • Med Changes

  • Suicidal/Homicidal Ideation Notes

  • Progress toward goals:

  • Active Goals:

  • Symptoms

  • Clinical Interventions Utilized/Discussed

  • Client receptiveness to interventions

  • Homework

  • Medical Necessity Notes

Template 2 : FBIRP

  • F-Focus- topic of session (can be tired directly into treatment plan goals/objectives)

  • B-Behavior- mood, affect, symptom reporting. I created a template on SP with check boxes.

  • I-Intervention- again, check box with things like CBT, ERP, Motivational interviewing, mindfulness, assertiveness training, etc.

  • R-Response- I’ll give my clinical assessment of progress, and use direct quotes from client during session.

  • P-Plan- I’ll update treatment plan goals, homework assignments, etc.

Example:

  • F-assertiveness training, ERP.

  • B- mood brighter than usual, client has good insight about core feats in being assertive. Reports decrease in symptoms over the week, feeling more relaxed and has been following through with homework practicing assertive interactions with others.

  • I- assertiveness training, communication skills, explored how core fears of disappointing others interferes with personal values.

  • R- client has good insight. Reports decrease in fears when taking risks and facing fears of disappointing others. Reviewed homework about conversation with coworker to manage workloads. Client reports feeling proud of how they handled the situation with coworker, and that workloads are more balanced.

  • P- continue assertiveness training, developed a fear hierarchy to implement with tasks at work surrounding core fears

Template 3: BIOP

  • B-Behavior

  • I-Intervention

  • O-Outcome

  • P-Plan

Example:

  • Behavior: "I noticed a theme of feeling unheard, you related it to an argument with your significant other. Would that be okay to put in our note?"

  • Intervention: "On my end I used EMDR history taking phase with you for the session. Yeah?"

  • Outcome: "You were able to identify an NC, emotion, somatic presentation, and we found 7 memories that relate to that present feeling g of not being heard. Yeah?"

  • Plan: " Would it be a good idea to explore resources to help you stay within your window of tolerance ar next session?"

Template 4: SOAP

  • Diagnosis

  • Justification

  • Risk Assessment

  • Medication Changes

  • SOAP Notes

    • S-Subjective

    • O-Objective

    • A-Assessment

    • P-Plan

  • Interventions

  • Progress Toward Goals

Example:

  • This first section has the diagnosis and Justification. I only have to do this once at intake unless I change the diagnosis I am using. Otherwise it pulls forward to each note.

  • Then you have the checkboxes, which I select “all normal” about 95% of the time (unless I see something different of course).

  • Then the risk assessment, which often is a checkbox for no risk noted.

  • Other than the diagnosis, These are all essential to include in all notes whether they are private pay or not.

  • Then there is the med section which I can generally select from the history box, it stays the same a lot.

  • Then you have Subjective and Objective.

    • Subjective, I put only a sentence or two. I try to use a quote from the client about how they are feeling that day like “I am doing better this week, my stress felt lower after I worked on the time management plan we talked about last week” OR “I am really feeling low, just like I am sitting in quicksand and I can’t get out of it. It’s hard right now.” Then maybe a sentence about any other symptoms they are expressing.

    • Objective- what we talked about. I do general terms, I don’t put details about conflicts they are having with others, but more like “explored the conflict she is having with her mother over finances and how this is impacting her depression. Discussed some conflict resolution techniques and ways this conflict repeats patterns from childhood.” I mostly focus on just the basics of what the person is struggling with and how it impacts their mental health.

  • Then you have checkboxes for interventions, progress on their goals- this pulls forward from intake, so I just need to check box the options from the pull down menu which are “progressing, maintained, regressed or deferred.”

  • Finally you have plan and assessment.

    • For assessment I can write my clinical opinion on their progress. Again, just a sentence or two. Sometimes I just pull from the history button the same thing I had the week before.

    • For plan- it’s usually continue current interventions and session frequency. Sometimes I might write we are lowering frequency because client is progressing and symptoms are lowered, sometimes I might write that I am going to update the care plan. Otherwise it’s the generic- continue sessions, interventions.

  • Ensuring you are assessing affect and risk and that you have a brief care plan you are evaluating for efficacy is really what insurance wants to see. It’s also, in my personal opinion, good practice without insurance because if someone ever came back with a lawsuit, I have documentation of these things

Template 5: GIRP

  • G-Goal

  • I-Intervention

  • R-Response

  • P-Plan

Ideas & Tips 

  • Go through previous notes and identify top 10 interventions, use those as checkboxes for session interventions with an 11th box for “other” with a fill in box

  • Collaborative Documentation at end of sessions

    • Session recap & document what’s agreed upon with client

Tools & Free Resources Recommended

Facebook Groups