The ins and outs of creating a paperless practice
Summary
Improve documentation time management by consolidating note-writing into dedicated time blocks, batching administrative tasks, and treating documentation time as non-negotiable appointments in your schedule.
Maximize clinical paperwork efficiency by using standardized templates like SOAP, DAP, or BIRP notes, keeping reusable documentation snippets, and completing notes as close to session time as possible.
Reduce documentation backlog by using voice dictation or AI note-taking tools, delegating non-clinical tasks to administrative staff, and always reviewing AI-generated notes for accuracy before signing.
It’s the end of your week and your last client session has just finished, but your work is far from done. Rather than heading off into the weekend right away, you feel buried in unfinished biopsychosocial assessments, progress notes, and discharge summaries. As you reflect on how this happened, you realize that you didn’t manage your documentation time well.
If this is a regular occurrence for you during your work days and weeks, there is a way forward. You can break the cycle and keep the admin from piling up by maximizing clinical paperwork efficiency and tackling other documentation and time management strategies.
Clinical paperwork efficiency
In addition to caring effectively for clients, therapists are expected to stay on top of their paperwork.
Each client requires an individualized treatment plan and every therapy session with them requires a progress note.
Staying on top of these administrative duties directly impacts your effectiveness as a therapist and your ability to avoid burnout. There is an expectation that documentation is completed in a timely manner. These expectations can come from governing boards and insurance companies, but they’re also an ethical obligation and should be a personal expectation.
When therapists can complete clinical paperwork efficiently, it reduces risks for clawbacks from insurance companies and keeps their work feeling more manageable and contained.
Administrative burden is one of the biggest known contributors to clinician burnout, so it’s in the best interest of every clinician to minimize that burden as much as possible.
How to streamline your process
One of the best ways to move away from the administrative burden is to streamline the documentation process.
There are several ways this can be done:
Use standardized templates and formats
When you use the same format for each assessment, progress note, or discharge summary, you will become very familiar with it and know what is expected in each section, which can reduce cognitive load and improve clinical paperwork efficiency.
Keep a library of documentation “snippets”
When documenting something like a specific modality (CBT, DBT, etc.) or mental status exam features (behavior, memory, etc.), a helpful documentation time management strategy is to have short blurbs already written that you can copy and paste into the note. These snippets can save the time of rewriting the same several sentences in each note.
You can paste the small blurb and then make any quick edits that might be needed to make it unique to the client. Keep in mind that they should not include personal health information (PHI) from other clients. Including PHI from another note would be a serious HIPAA violation.
Focus only on the required elements
When documenting, think about the required elements only. Avoid including extraneous details that aren't clinically relevant or required by your payer.
For example, progress notes for an insurance client would require items like client symptoms and evidence of medical necessity, specific evidence-based interventions utilized, client’s response to the interventions, and progress toward treatment goals.
Use voice to text or AI
The use of a voice dictation app can help improve clinical paperwork efficiency. If you can perform the dictation soon after the session ends, you can meet time requirements for notes and retain more details about the session.
AI note takers are also growing in popularity among therapists focused on documentation time management. The AI tool records the session and then the notes are produced at the end of session.
Consolidate documentation times
The dual responsibilities and expectation to move back and forth between clinician presence and documentation can take a toll. This can create switching costs—the time and focus lost every time you shift between different types of tasks.
Consolidation of documentation time can be one of the most effective tools for documentation time management. This can look like leaving 10 to 15 minutes at the end of a session before your next session begins, however, for some people this can be a challenge.
Batching session times together and documentation time in your daily schedule can be an effective strategy. For example, you might see clients from 10 AM to 4 PM and then leave 4 to 5 PM scheduled for documentation time.
It can also be helpful to batch the administrative tasks (like one section of time for notes and treatment plans, one section of time for billing and claims, one section of time for emails and client communication). Seeing this time blocked out on the calendar can make a significant difference for documentation time management.
What templates work best?
There are a variety of different note templates, and the one you choose matters for clinical paperwork efficiency. Choose the ones that are very clear, simple, and prompt you to enter only necessary information.
Some of the most commonly used templates are SOAP, BIRP, and DAP notes:
SOAP notes follow the SOAP format, which stands for Subjective, Objective, Assessment, and Plan—the four sections that make up the note. This is probably the most standardized format used across healthcare but the four sections can feel more cumbersome.
DAP notes, which stands for Data, Assessment, and Plan, are a more condensed version of the SOAP note and can move a bit faster with only three sections.
BIRP notes stand for Behavior, Intervention, Response, and Plan, and are used to track observable client behaviors and outcomes.
Any of these note templates are options to consider when deciding which templates work best for your situation. What is most important is that you choose a template you feel most comfortable and familiar with as that will lead to the best documentation time management.
When to complete notes
Some consider it best practice to have notes completed and signed the same day that the session occurred. However, that kind of clinical paperwork efficiency isn’t always possible.
For purposes of memory and detail clarity, it helps to complete the note as close to the session time as possible. Some clinics and organizations will have their own policies for when to complete notes. Commercial insurance companies often require notes to be completed within 72 hours, though this can vary, so it is wise to check with specific insurance providers for their requirements.
Medicare and Medicaid requirements for when to complete notes are often within 24 to 72 hours of the session, though this varies by state and program, so check with your specific payer for requirements.
When notes aren’t completed within these deadlines, the reliability of memory and detail from the sessions can be called into question. It also runs the risk of insurance claims being denied, payments being delayed, or having a clawback occur if your notes get audited.
How to avoid backlog
Unfinished notes can pile up fast. To avoid the backlog, it’s important to treat note time as non-negotiable, just like any other appointment time. Having some extra time set at the end of your work week can also help to avoid having notes hanging over your head going into the weekend.
Make sure that you block off enough time to complete the notes, and set reminders to check for unfinished notes at certain points in the week. Some electronic health records (EHRs) will automatically send you a notification when your notes are not completed within a certain amount of time.
If possible, delegate non-clinical tasks to admin team members. This allows you to stay focused on sessions and notes for optimized documentation time management.
What about voice dictation? How to maintain quality
Voice dictation is one option for documentation time management. A 2022 study published in the Journal of General Internal Medicine showed that among U.S. healthcare providers using an EHR, those who used voice dictation tended to spend less time on notes.
Dictation can reduce the amount of time sitting down to manually type things out. It’s important to note, however, that studies have found errors in dictation software notes, which means that it’s necessary to set aside time to review the notes and make edits when necessary.
AI note takers are emerging as an advanced version of this. The AI tool records the conversation between you and your client and produces a SOAP or DAP note at the end of the session for maximum clinical paperwork efficiency.
Studies show that these tools can improve documentation efficiency, but emphasize the importance of taking time to review and edit the note.
It is important to note that to utilize an AI note taker, you must get permission from the client and ensure the tool you’re using is HIPAA compliant. Additionally, verify that your state licensing board and professional liability insurance policy allow session recording, as some have specific restrictions.
Conclusion
With these documentation time management strategies in place, the end of the week can feel completely different. Instead of drowning in unfinished notes, you can close your laptop with a sense of accomplishment and no backlog hanging over your head.
This week, pick one strategy to implement. Your time management will start to improve, your documentation burden will lighten, and your Friday pile-ups will become a thing of the past.
Sources
American Psychological Association. (2006). Multitasking: Switching costs.
Ng, J. J. W., Wang, E., Zhou, X., Zhou, K. X., Goh, C. X. L., et al. (2025). Evaluating the performance of artificial intelligence-based speech recognition for clinical documentation: A systematic review. BMC Medical Informatics and Decision Making.
PESI. (2025). Meeting deadlines for progress notes in mental health.
Rotenstein, L. S., Apathy, N., Holmgren, A. J., & Bates, D. W. (2022). Physician note composition patterns and time on the EHR across specialty types: A national, cross-sectional study. Journal of General Internal Medicine.
Rupert, P. A., & Morgan, D. J. (2005). Work setting and burnout among professional psychologists. Professional Psychology: Research and Practice.
Zhou, L., Blackley, S. V., Kowalski, L., Doan, H., Acker, C., et al. (2018). Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists. JAMA Network Open.
How SimplePractice streamlines running your practice
SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.
If you’ve been considering switching to an EHR system, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.
Try SimplePractice free for 30 days. No credit card required.
