In the field of psychology, the job does not end when the client leaves the room. With each hour spent doing therapy, another equally important time is spent in the “paper trail.” Mental health documentation goes beyond being another form of paperwork for the office; rather, documentation is an important tool of excellent care.
Whether you are a college student, a young clinician, or a seasoned psychologist wanting to optimize your process, this guide takes a comprehensive look at the types of documentation practices in the mental health industry, popular types, examples, and more!
Why Is Documentation So Important?
Before we look at the specific examples, we must understand the “why.” In the clinical world, there is a famous saying: “If it isn’t documented, it didn’t happen.”
- Continuity of Care: Detailed notes ensure that if a client sees a different provider, the new clinician understands the history, progress, and treatment trajectory.
- Clinical Clarity: Writing notes helps the psychologist process the session, identify patterns, and refine the treatment plan.
- Legal Defense: In the event of a malpractice suit or a board complaint, your notes are your primary evidence that you met the standard of care.
- Insurance Reimbursement: Insurance companies require proof that the services provided were “medically necessary.” Without proper documentation, they may claw back payments.
- Ethical Responsibility: According to the American Psychological Association (APA) Ethics Code, psychologists have a duty to maintain accurate records.
1. The Biopsychosocial Intake Assessment
The intake is the foundation of the therapeutic relationship. It is the first comprehensive document created for a client.
What it Includes:
- Identifying Information: Age, gender, relationship status.
- Chief Complaint: Why is the client seeking help now?
- History of Presenting Illness: When did the symptoms start?
- Psychiatric History: Previous diagnoses, hospitalizations, or therapy.
- Medical History: Chronic illnesses, medications.
- Social/Family History: Upbringing, support systems, employment.
- Mental Status Exam (MSE): The psychologist’s observation of the client’s current state (appearance, mood, affect, thought process).
Example: Mental Status Exam (MSE) Entry
“The client appeared groomed and dressed appropriately for the weather. Speech was normal in rate and volume. Mood was reported as ‘anxious,’ and affect was constricted. Thought process was linear and goal-directed. No evidence of hallucinations or delusions. Insight and judgment appear fair.”
2. Treatment Plans (The “Golden Thread”)
The treatment plan is a roadmap for therapy. It must follow the “Golden Thread” logic: the diagnosis leads to a goal, which leads to an intervention, which is documented in the progress notes.
Using the SMART Goal Format:
- Specific
- Measurable
- Attainable
- Relevant
- Time-bound
Example: Treatment Plan for Generalised Anxiety Disorder (GAD)
- Diagnostic Code: F41.1 (GAD)
- Problem: Client reports excessive worry and physical tension occurring most days for 6 months.
- Goal: Reduce frequency of panic attacks from 3 times per week to 0 times per week.
- Objective: Client will learn and practice three relaxation techniques (deep breathing, progressive muscle relaxation) within the next 4 weeks.
- Intervention: Therapist will use Cognitive Behavioral Therapy (CBT) to help the client identify and challenge irrational thought patterns.
3. Progress Notes: The Three Main Formats
Progress notes are the most frequent type of documentation. Psychologists generally use one of three common formats: SOAP, BIRP, or DAP.
A. The SOAP Note
SOAP is the most traditional format, used widely across the medical field.
- S (Subjective): What the client says. Direct quotes are helpful.
- O (Objective): What the therapist observes (body language, MSE).
- A (Assessment): The clinician’s clinical impression. Is the client improving?
- P (Plan): What happens next? When is the next session?
SOAP Note Example: Major Depressive Disorder
- Subjective: Client stated, “I didn’t get out of bed until 2 PM three days this week. I feel like I’m failing at everything.”
- Objective: Client’s hygiene appeared neglected. Eye contact was poor. Movement was lethargic (psychomotor retardation).
- Assessment: Client is experiencing a moderate exacerbation of depressive symptoms, likely triggered by recent job loss. Risk for self-harm remained low.
- Plan: Continue weekly CBT. Assigned homework: “Behavioral Activation”—client to take a 10-minute walk daily. Next session scheduled for Tuesday.
B. The BIRP Note
BIRP is popular in behavioral health because it focuses heavily on the therapist’s interventions.
- B (Behavior): Observations and client statements.
- I (Intervention): What the therapist did during the session.
- R (Response): How the client responded to the intervention.
- P (Plan): The follow-up.
BIRP Note Example: Social Anxiety
- Behavior: Client reported avoiding a work holiday party due to fear of being judged. Appeared fidgety, wringing hands.
- Intervention: Therapist led a role-playing exercise to practice “small talk” techniques and used cognitive restructuring to challenge the thought “everyone will think I’m weird.”
- Response: Client initially resisted the role-play but eventually engaged. Reported a 3/10 reduction in anxiety by the end of the exercise.
- Plan: Client will attend a small coffee gathering with one friend this weekend as a “graded exposure” task.
C. The DAP Note
DAP is a streamlined version often used in fast-paced clinical settings.
- D (Data): Both subjective and objective information.
- A (Assessment): Clinical interpretation.
- P (Plan): Future steps.
DAP Note Example: Post-Traumatic Stress Disorder (PTSD)
- Data: Client discussed a “flashback” triggered by a loud noise at a construction site. Client utilized the “5-4-3-2-1” grounding technique learned in the previous session. Heart rate was visibly elevated during the retelling.
- Assessment: Client demonstrates an increasing ability to utilize coping skills in real-time, though hypervigilance remains high.
- Plan: Introduce EMDR (Eye Movement Desensitization and Reprocessing) protocols in the next session to address the specific trigger.
4. Crisis Documentation and Safety Planning
When a client expresses suicidal ideation or self-harm, documentation must be incredibly detailed. You need to prove that you assessed the risk and took appropriate action.
Key Elements to Document:
- Presence of a plan, means, and intent.
- Protective factors (family, pets, religious beliefs).
- The “Safety Plan” created with the client.
Example: Crisis Assessment Entry
“Client expressed passive thoughts of death, stating ‘I wish I didn’t wake up.’ Upon further questioning, client denied a specific plan or intent. Client has no history of attempts. Protective factors include a strong relationship with her sister and her dog. We co-created a safety plan which includes calling the 988 Suicide & Crisis Lifeline if thoughts intensify. Client agreed to remove old prescriptions from the home.”
5. Discharge Summaries
The discharge summary is the final piece of the puzzle. It summarizes the entire course of treatment.
What it Includes:
- Reason for discharge (Goals met, client moved, insurance ended).
- Status at the beginning vs. status at the end.
- Recommendations for the future.
Example: Discharge Summary
- Initial Presentation: Client entered therapy with severe Panic Disorder, experiencing 5+ attacks weekly.
- Course of Treatment: 12 sessions of CBT. Client learned to identify physiological cues of panic.
- Outcome: Client reports 0 panic attacks in the last month. GAD-7 score decreased from 18 to 4.
- Reason for Discharge: Mutual agreement that goals have been met.
- Recommendation: Client to continue daily mindfulness and return for “booster sessions” if symptoms return during high-stress periods.
Tips for Better Documentation
Writing thousands of words a week can be exhausting. Here are some tips to keep your documentation efficient and high-quality:
- Be Objective: Instead of saying “The client was angry,” say “The client’s voice became loud, and they used profanity when discussing their spouse.”
- Use Collaborative Documentation: If possible, write parts of the note with the client at the end of the session. This builds rapport and saves time.
- Use EHR Software: Electronic Health Records like TherapyNotes or SimplePractice offer templates that make this process much faster.
- Proofread for HIPAA: Ensure you aren’t leaving identifiable information in places where it doesn’t belong. Always follow HIPAA Privacy Rules.
- Don’t Postpone: The best notes are written within 24 hours of the session. Memory fades quickly, and “note debt” is a leading cause of burnout among psychologists.
Ethical and Legal Links for Further Reading
To stay up to date on the standards of documentation, psychologists should regularly review resources from governing bodies:
- APA Record Keeping Guidelines: Read more here
- The “Open Notes” Rule (21st Century Cures Act): This federal law allows patients easy access to their electronic health records, including therapy notes. Learn about the Cures Act here.
- NASW Standards for Technology in Social Work: (Useful for LCSWs and psychologists alike) Link to NASW.
Conclusion
Mental health documentation is as much an art as it is a science. It may seem like “just paperwork,” but it’s truly the narrative of a person’s journey toward healing. Coupled with psychologists using structured formats such as SOAP or BIRP and keeping intact the “Golden Thread” from intake to discharge, they make sure that not only is the quality of their provided standard of care safeguarded but, similarly, their professional practice.
Remember, clear notes lead to clear thinking, and with clear thinking come better clinical outcomes.
Disclaimer: This blog post is for informational purposes only and does not constitute legal or clinical advice. Always consult your state licensing board and professional associations for specific documentation requirements in your jurisdiction.
