Therapy Notes Template
Implement this intuitive therapy notes template into your business and achieve improved documentation, higher accuracy, and better clinical outcomes: all while saving time.
Fact Checked by Ericka Pingol.
What is a Therapy Notes Template?
Every healthcare practitioner is required to write clinical documentation, providing a detailed record of a patient’s experience within the healthcare system. Therapy notes form this broader collection of clinical documentation, and are records written by therapists following an encounter or session with a patient. Therapy notes, also called psychotherapy notes, are not legal documents, which separates them from progress notes. This form of documentation has the primary purpose of reminding therapists of important details from previous sessions with clients. They help to ensure that clinical decisions are always informed and that patients are receiving the best quality care possible. To help therapists create well-structured and effective notes in a timely manner, we have created an intuitive therapy note template. In this guide, we’ll explain how you can implement it within your practice, as well as provide some of the most significant benefits that are associated with using our template. Let’s get started!
Free Therapy Note Templates
Check out these note templates for therapists to improve clinical documentation, productivity, and treatment outcomes.
How to Use This Template for Therapy Notes
Fortunately, the process of implementing this therapy note template into your practice is very simple. You just have to follow these three steps:
Step One: Download the PDF
The first thing you need to do is download the PDF template. We have included a link to the document on this page, and you simply have to click on this and you’ll be taken to a PDF reader on your device. From here, you can download the document onto your device where it can be directly edited or printed out if you’d prefer a physical copy.
Step Two: Complete the note
After you’ve had a session with a client, it’s time to complete the therapy note. If you have already downloaded the template onto your device then accessing it will be very easy. After you’ve opened the template, you can begin filling out the relevant sections with information from your client session.
Step Three: Double-check date and time
Before you save and complete the therapy note, you should double-check that you’ve included the correct date and time. Therapy notes help therapists obtain a comprehensive overview of the patient’s wellbeing and treatment progress and in order for this to be accurate, the notes need to have the correct date and time.
Step Four: Save the note securely
Although therapy notes aren’t legal documents, they still need to be stored securely. After you have finished writing the note, you need to store it somewhere that it will be protected by physical and/or electronic safeguards. In order to comply with HIPAA guidelines and protect both your patients and yourself, these documents need to be inaccessible to everyone but authorized users.
Therapy Notes Example (Sample)
We have created an example therapy notes template with each relevant section filled out. This document should provide you with an insight into how the template functions, as well as the type of information that is typically included in each section.
Download this Therapy Notes Example (Sample) here:
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Who Can Use this Printable Therapy Note Template?
This therapy note template, as the name suggests, has been designed primarily with therapists in mind. That being said, there is quite a bit of flexibility involved with the template. As I’m sure you may know, clinical documentation can be written according to a range of different formats and structures. Rather than impose one of these formats onto template sections, we have deliberately chosen to leave the notes section free, allowing therapists to decide for themselves how they want to format the note. We also think that this specific template can be applicable to the following care providers:
- Mental Health Therapists
- Counselors (Grief, Family, Drug, Youth).
- Psychologists
- Social Workers
If you work in one of the above fields and have regular interactions with patients, then our template will definitely be suited to your work. All you have to do is download the document and leave it somewhere accessible, where you can retrieve it at a later date. This template will also definitely be fine to use regardless of your experience. You may be a trainee therapist or you may have been working in the field for upwards of 30 years but either way, this note template will benefit your work in some way.
Why is This Template Useful For Therapists?
Not only has this therapist note template been designed to be easily implemented within practices, but it is also varied in its usefulness. Some of the uses associated with this template include:
- Organization: Using a therapy notes template is guaranteed to elevate the organization of your documentation. It can be hard for therapists (particularly those who see a lot of patients) to maintain organized notes, but with our template, this aspect of documentation is done for you.
- Consistency: This template will also ensure that the therapy notes that you write have a consistent format. Although these documents aren’t intended to be shared between other third-parties, consistency will make it easier for you to quickly scan the notes and extract relevant information.
- Accuracy: One of the primary purposes of writing therapy notes is to remind practitioners of specific details regarding a session with a patient. If the information included in the note isn’t completely accurate, then the note itself loses credibility. Included in our template are different sections for general notes as well as date/time markers, helping you ensure that you have recorded important and accurate details.
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Why Use Carepatron For Therapy Notes?
Clinical documentation is the backbone of the healthcare industry, and finding ways to optimize these processes is always in the best interest of therapy businesses. This is where Carepatron can help. An all-in-one online practice management software, Carepatron has been designed in collaboration with healthcare practitioners to provide solutions to different businesses. The platform has a range of different tools, including voice-to-text transcription software and a robust set of templates, that will help your practice create accurate notes in half the time. Carepatron is also integrated with storage capabilities that are HIPAA-compliant. This means you can create and store your notes in the system without worrying about data being leaked or hacked.
It would be remiss of us not to mention some of the other practice management areas that Carepatron excels in. In addition to clinical documentation, the platform has medical billing, appointment scheduling, patient engagement, and mobile health solutions. All of these tools will enable your therapy practice to improve its administrative processes so it can focus on effectively caring for patients.
Commonly asked questions
The contents of a therapy note will differ depending on the specific session that you have with a client, but they should typically cover your general thoughts, ideas, hypotheses, or observations that you’ve had.
No. Unlike progress notes, you are not legally required to share your therapy notes with your patients. There are some situations where patients may request access to your private notes and you may have to accept this request, but these occurrences are rare.
Once again, this is dependent on the content of the session and the information that you want to record. Because you’ll also need to be writing progress notes after your sessions with clients, you may choose to only write therapy notes after an important or comprehensive session. You may also find that sometimes your therapy notes are only a few lines whereas other times they could be a full page. At the end of the day, as long as you are detailed, accurate, and honest, the actual length of these notes doesn’t matter.
