Psychotherapy notes are an important part of telemental health, as any therapist or counselor will know.
But how well do you know the difference between therapy notes and progress notes, or the best practices for writing and storing these important records?
This article covers some of the top tips to help you create efficient, expertly written, and HIPAA-compliant psychotherapy notes to deliver higher caliber mental health services to all your clients.
What Are Psychotherapy Notes?
Psychotherapy notes are the documents a counselor, telecounselor, therapist, or mental health specialist makes regarding their client, typically during or immediately after a therapy session.
They are a private, confidential record of the psychologist’s opinions and feelings about a session, their patient, and any hypotheses they may have about their condition, treatment, mental health status, or progress with the therapy. 
More technically, the Health Information Portability and Accountability Act (HIPAA), uses the term ‘psychotherapy notes’ to refer to:
Notes recorded in any medium by a mental health professional documenting or analyzing the contents of conversation during a private counseling session.
Unlike Progress Notes, which may contain medical information, appointment start and stop times, and/or patient identifiers, psychotherapy notes are not shared with a client or any other provider involved in their mental health treatment plan.
Types of Psychotherapy Notes: Practical Examples
In e-mental health, there are several well-known formats that can be used to create different types of psychotherapy notes.
To writing informative, effective therapy notes, clinicians need to address certain criteria. But with no formal template for psychotherapy notes, that can sometimes seem overwhelming.
Fortunately, note-taking doesn’t need to take record time. In e-mental health, several well-known formats can be used to create different types of psychotherapy notes. Some of the most popular therapy notes templates include:
Structured yet versatile, these useful formats are handy acronyms – each corresponding to the various headings or key sections within each type of therapy note. SOAP, BIRP, and DAP templates can serve as mental checklists for the core content that needs to be included while giving a systematic approach to writing documents useful for future reference.
SOAP Therapy Notes
The S, O, A, and P of SOAP denote four different types of information that a therapist gathers and builds from an appointment with a client.
This template provides an easy way for psychologists to combine Subjective data and Objective data from their therapy session in an Assessment section, before evaluating and possibly amending a patient’s Treatment Plan.
Subjective data often comes from a patient’s reports, direct quotes, or information provided by a caregiver. They might concern the client’s experiences since the last session or with the treatment and include their opinions, thoughts, or feelings.
Psychologists often include their own subjective data here, noting what they gleaned from their client’s behavior, appearance, or affect.
Objective data, such as test results or similar, are recorded separately here. As behavioral health relies heavily on interpretation, this header might be considered an ‘Observation’ section.
While not commonly seen in psychotherapy notes, healthcare contexts more generally might use this section for examination results, vital signs, and more.
This section is for analyzing the objective and subjective information in an integrated way.
Diagnoses may be offered, interpretations summarized, or alternative hypotheses suggested, and a therapist will typically draw inferences about the patient’s mental health status here.
Finally, a client’s treatment plan is evaluated, or notes about a potential treatment plan are given.
A more detailed overview of their treatment plan may be found elsewhere in a patient’s chart, such as in their progress notes. If this is the case, a therapist will detail specific actions that need to occur, amendments to their psychotherapy program, or any interventions they are considering.
BIRP Therapy Notes
BIRP stands for Behavior, Intervention, Response, and Plan. As with SOAP notes, they can be used for individual therapy notes, group therapy, assessments, and evaluations, in addition to many other session types.
As BIRP notes are commonly used in conventional and digital healthcare, many practice management systems include templates built on these templates.
Subjective and objective data are both included in an initial description of the client’s behavior. This section answers questions about a clinician’s observations of a client and reports and direct quotes from the patient or their caregiver.
When used to structure Progress Notes, the BIRP format might include test or psychological assessment data here, but this is not commonly the case with psychotherapy notes.
|Once all relevant facts regarding the patient’s behavior have been recorded, the Intervention section addresses the techniques, and psychological tools applied.|
This section includes session goals, the client’s challenge or problem, what happened during the appointment, and different techniques or methods applied as part of the treatment.
The Response section addresses how clients reacted to the intervention, their progress, and their treatment plan more broadly.
As with SOAP notes, the final section includes a psychologist’s professional opinion on how the client’s treatment plan should continue or be amended if action is considered appropriate.
DAP Therapy Notes
DAP notes combine subjective and objective information into one Data section, which – like the previous two formats – is followed by Assessment and Plan.
Here, notes relate to data the psychologist has observed throughout the appointment. Specific behaviors they noticed, the client’s appearance, traits, and any other information that could shape their recommendations for the treatment plan should be included.
Based on the Data above, a psychotherapist uses this section for analysis. Describe your interpretations here and any inferences you might make from the information you gathered.
Finally, these inferences are used to inform any next steps regarding the patient’s treatment plan.
6 Helpful Templates For Your Practice
As an e-mental health specialist, private practice software with therapy notes templates can greatly speed up psychotherapy documentation.
Our SOAP and BIRP note articles are full of examples, templates, and formats that you can use to structure your notes, while our Therapy Progress Notes resource offers handy step-by-step guides that you can customize.
If you prefer a free downloadable outline, some useful examples include:
- The University of Illinois’ College of Medicine – a very basic SOAP note framework that is free to download and offers subheading suggestions for key elements
- This Drake University SOAP note template – a more detailed mental health therapy notes checklist including relevant subheaders for prescribing clinicians, and
- The Alameda County Behavioral Health BIRP note template
Digital Solutions: 4 Software and Apps To Start Using Today
|ICANotes is a practice management solution with treatment planning, e-prescribing, documentation, Psychotherapy Notes, and Progress Notes features, and is one of the more comprehensive EHR systems for large providers.|
It can be used by prescribing psychiatrists, telemedical providers, e-psychologists, and therapists with a massive database of mental health and medical codes. E-signatures, templates, and document locking are all part of the package with this team and solo practitioner software.
|Good For||Psychologists, Psychiatrists, Telemedical Providers|
|TherapyZen includes both templates and a custom form creator that allows users to include standard sections and elements.|
HIPAA-compliant and easy to use. This software includes clinical codes, standard interventions and assessments, and easy formatting of psychotherapy notes – it also has handy drop-down menus for evaluations with clients.
|Good For||Psychologists, Counselors, Therapists|
|MyClientsPlus has a huge collection of over 200 mental health and psychotherapy note templates for practitioners to customize, including psychiatric notes, counseling templates, DAP templates, SOAP note formats, and more.|
Using MCP, clinicians can avoid manual typing of diagnostic codes – as a therapy solution, the system includes configured DSM and ICD codes for quick input. MyClientsPlus also provides customizable headlines for branded content, supports batch printing of notes, and allows quick and easy e-signatures.
|Good For||Counselors, e-Therapists, Mental Health Coaches, Psychologists|
|Psychiatrists, counselors, therapists, and clinicians will find TherapyNotes templates useful thanks to specialty formats that follow APA guidelines. This software stores notes in a HIPAA-compliant EHR and even pulls forward appointment data such as session dates and times.|
Dropdown menus, custom text fields, and speech-to-text capabilities all make TherapyNotes’ documentation features even more user-friendly while helping you fill in all important fields for reliable, clear notes.
|Good For||Psychologists, e-Counselors, Therapists, Mental Health Coaches|
7 Tips For HIPAA Compliant Notes
Unlike progress notes, the documentation made by a therapist during a session is private and confidential. Using a mental health software solution is the easiest, most reliable way to ensure electronic psychotherapy notes are HIPAA-compliant.
But while specially designed private practice and e-clinic solutions encrypt and store your confidential notes in accordance with the legal requirements for practicing e-psychologists, there are still important guidelines to follow to keep your therapy notes secure.
Using the American Psychological Association (APA) advice as a guide, your notes should be:
- Password-protected: Both software and screensaver login requirements can help prevent accidental, unauthorized access to your notes
- Encrypted: HIPAA dictates that teletherapy equipment should be carefully controlled – encryption adds another layer of protection to private documents
- Backed up: As a practitioner, you are responsible under HIPAA for backing up your patient data. Consider an encrypted external hard drive or choose a cloud-based practice management solution.
- Covered by a signed agreement: Legally, protecting psychotherapy notes means having a ‘framework’ in place to ensure their proper storage. A signed formal contract between practitioners and their EHR or software providers is one way to fulfill this requirement.
- Accessed using a secure Wi-Fi connection: Locking your home Wi-Fi network to prevent third-party access or assigning different user logins at a healthcare organization will further protect your notes under HIPAA, and
- Protected from intrusion: Using any appropriate malware-prevention programs.
In addition to all the above, it’s good practice to document all the steps you have taken to make your psychotherapy documents HIPAA-compliant. Under the legislation, practitioners are required to do both this and assign a Privacy Officer responsible for ensuring the framework is upheld.
Writing psychotherapy notes doesn’t have to be like navigating a minefield. With helpful software, templates, and some sharp observation skills, your therapy documents can quickly become helpful resources to inform your client’s treatment plan.
If you’re looking for more information on protecting your notes under HIPAA, or how you can integrate your notes with your other practice admin, our E-Health archives are a great place to start. Do leave a comment if you have any advice to help your fellow practitioners create effective, efficient therapy notes.
- ^ HHS.gov. (2017). Combined Text of All Rules. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/combined-regulation-text/index.html
- ^ APA. (2003). More protections for patients and psychologists under HIPAA. Retrieved from https://www.apa.org/monitor/feb03/hipaa
- ^ MyClientsPlus. (2020). Writing DAP Progress Notes: 3 Tips for Organizing Your Therapy Notes. Retrieved from https://www.myclientsplus.com/blog/writing-dap-progress-notes-3-tips-for-organizing-your-therapy-notes
- ^ American Psychological Association. (2007). Record keeping guidelines. American Psychologist, 62(9), 993.