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.

By Ericka Pingol on Jul 15, 2024.

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Fact Checked by Ericka Pingol.

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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!

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.

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.

Benefits of Therapy Notes

This therapy note template will also contribute to a range of different benefits, both for you as a practitioner and also for the wider practice where you work.

Streamlined workflow

Because the schedule and workflow of most therapist businesses are typically very busy, it is helpful to find ways that streamline processes without compromising the quality of work. With our therapy notes template, you can reduce the amount of time you spend writing documentation without reducing the effectiveness of the notes.

Informed clinical decisions

As we have explained, one of the main aims of this kind of documentation is reminding therapists of key pieces of information concerning their patients. By writing consistent and organized therapy notes, you will ensure that you are always well-informed when it comes to making informed decisions regarding your client’s treatment.

Client relationships

Building meaningful and long-lasting relationships with clients is a very important aspect of working as a therapist. Although there are a multitude of factors that contribute to these relationships, writing good notes and consequently making good clinical decisions is one of the best ways that you can focus on patient relationships.

Communication

Although therapy notes aren’t primarily designed to be shared between different third-parties, they can still play an important role in maintaining effective communication. The information that is recorded in therapy notes can be used to develop an informed understanding of a patient’s current health condition and general treatment progress, and this knowledge can be relayed to other members of the care team or even insurance providers.

Track patient progress

While therapy notes aren’t explicitly progress notes, they still have a role to play in analyzing and assessing patient progress. Therapists can refer back to notes from previous sessions and compare them to determine how much a patient has improved. Being able to properly understand how a patient is responding to treatment is imperative to achieving good clinical outcomes and ensuring the needs of the patient are being met.

What should be included in a therapy note?
What should be included in a therapy note?

Commonly asked questions

What should be included in a therapy note?

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. 

Can my patient read my therapy notes?

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.

How long should my therapy notes be?

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.

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