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Summary
Clinicians can improve efficiency and compliance by following clinical note best practices and structured documentation standards that ensure accurate recording of assessment data, treatment plans, progress, and safety information.
Effective therapy documentation guidelines recommend including essential session details such as informed consent, clinical observations, diagnoses, outcome measures, and clearly defined treatment goals tailored to insurance or self-pay requirements.
Time-efficient documentation strategies include using templates, writing notes immediately after sessions, leveraging speech-to-text tools, and applying standardized formats like SOAP, DAP, BIRP, or GIRP to streamline clinical workflows.
Documentation is often one of the more challenging and less enjoyable parts of clinical work for many clinicians.
However, at a time when insurance companies have dedicated audit and recovery departments that may initiate recoupments when documentation does not support claims, there is added pressure to ensure notes are completed promptly and contain the right information.
This article covers clinical note best practices and therapy documentation guidelines, including a quick guide on what must be included, when to write notes, how to be time efficient with note-taking, how to handle corrections, and more.
What must be included in clinical notes?
Clinical note best practices emphasize documenting relevant clinical, administrative, and safety information in a structured format.
Therapy notes should document a brief record of your encounter with a client(s), recording:
Informed consent
Treatment plans and interventions
Clinical observations and diagnoses
Progress toward treatment goals
Administrative data
Measures used
Therapy documentation guidelines differ depending on whether you are completing an assessment, creating a progress note, or recording a crisis or safety intervention. They may also vary depending on specific insurance requirements.
For example, clinicians who do not bill insurance can record more concise notes and do not need to include diagnosis codes. In contrast, some insurance companies require clinicians to justify medical necessity, undergo audits, and generally require more extensive record-keeping.
According to clinical note best practices, documentation should begin with clear and consistent session details. Therapy documentation guidelines also help standardize what information should be captured during and after each session.
Clinical notes should include the following information:
Session details: Date, time, duration of the session (including start and end times), clinician’s name, qualifications, CPT code (if billing insurance), location of provider and client, and type of session (intake, assessment, treatment session, etc.).
Informed consent: Record that informed consent was obtained.
Assessment information: Presenting problem(s), symptoms, description of symptoms or problem in the client's own words, social, psychological, and medical history, stressors, risk and protective factors, demographic and identifying information (name, gender identity and pronouns, sexual orientation (if they feel comfortable disclosing), and safety screening data.
Treatment plan: Goals, objectives, interventions, session duration, and session frequency recommended. If recording a progress note, therapists include the interventions used.
Clinical observations and diagnoses: Mental status exam, diagnosis (including relevant ICD-10 codes if billing insurance), and clinical justification for those diagnoses.
Progress information: Client reports and clinical observations, interventions, and changes in diagnosis and treatment goals.
Plan: Date and time of next session, follow-up actions, referrals, and resources provided to the client.
Additional information may include:
Administrative data: Any relevant information, like referrals, documents completed in session, and a record of any paperwork that needs to be completed.
Measure records: Regular assessment information, such as PHQ-9, GAD-7, or PCL-5.
Safety information: Suicide screening, safety plans, and safety-specific referrals made.
In addition to content requirements, clinical note best practices focus on improving efficiency in documentation workflows.
How to be time efficient with documentation
The following strategies outline how to be time efficient with note-taking in clinical documentation:
Make concurrent notes during the session.
Use collaborative note-taking.
Use a template such as SOAP, DAP, BIRP, or GIRP notes (see the format section below).
Write notes immediately after the session.
Block out 30 to 60 minutes specifically for notes, and complete them in batches.
Create a template in your electronic health record (EHR).
Dictate notes or use speech-to-text software.
Use AI to record notes (when permitted by agency policy, legal requirements, and with appropriate client consent).
Separate psychotherapy notes and progress notes.
Focus on clinical information and avoid overdocumenting, ensuring you record clinical observations, reasoning, safety assessment, and reflect meeting standards of care.
Clinical note best practices also address how to appropriately manage late entries while maintaining compliance and accuracy.
What about late entries?
Therapy documentation guidelines provide clear expectations for how clinicians should handle late entries and corrections while maintaining compliance. While it is best practice to make clinical notes within 24 to 48 hours after the session, late notes happen.
When making a late entry, ensure you record the date and time of the note, as well as when the session occurred. You may add that your note is a late entry or that you have made the note to the best of your recollection.
What format works best for clinical notes?
The most common therapy note formats include:
SOAP notes
Subjective: Client’s self-reports about their presenting problem, symptoms, and relevant history.
Objective: Clinician observations, such as mental status exam and relevant medical records from other providers.
Assessment: Therapist assessment based on the subjective and objective information, and other relevant sources.
Plan: Details about next steps in treatment, referrals, interventions, and resources.
BIRP notes
Behavior: Observations and client information about their progress since the last session, symptoms, behavior observed in session, and clinician assessment of their motivation, orientation, and appearance. This section may include client quotes.
Intervention: The interventions used as part of treatment and how they relate to the diagnosis and treatment goals.
Response: Observations of how the client has responded to interventions and effectiveness. This section should include any unsuccessful interventions and steps the therapist has taken if the relationship was affected.
Plan: Date and time of the next session, referrals, homework, resources, and consultations.
DAP notes
Data: Client's reason for visit, including symptoms and other relevant information since the last session, and therapist observations.
Assessment: Clinician’s assessment of progress in relation to treatment goals, response to interventions, change in diagnosis, and treatment plan/goals
Plan: Next session, referrals made, resources provided, and any homework or next steps before the next session.
GIRP notes
Goal: The treatment goal worked on during the session.
Intervention: The interventions used. For example, EMDR, CBT, and DBT.
Response: How the client responded to the intervention. For example, “client practiced the WISE mind skill.”
Plan: The next scheduled session, referrals, measures, homework, and resources provided.
How to handle corrections
When clinicians need to correct a note, it is best practice to add an addendum to the note stating why you are correcting the note, the note’s original date, and new or corrected information, then add a signature and credentials. For example, “The original note, dated 10 March 2026, incorrectly stated the client was experiencing suicidal ideation. Error corrected for accuracy.”
Following clinical note best practices ensures documentation is both clinically meaningful and compliant with professional and insurance standards.
Sources
American Psychological Association. (2024). Record Keeping Guidelines.
Centers for Medicare & Medicaid Services. (2015). Medical documentation for behavioral health practitioners: Fact sheet [PDF]. U.S. Department of Health and Human Services.
Cook, G. (2025). Transform Your Note Taking. American Counseling Association.
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