Psychotherapy Note Template

What is a Psychotherapy Note Template?

A psychotherapy note refers to a therapist’s private notes regarding a session or general encounter with a patient. Psychotherapy notes differ from progress notes in their status as non-legal, optional documents that are not made to be shared. In turn, a progress note is a legal, required document that is frequently shared between all members of a patient’s care team, insurance providers, and even lawyers. In order for psychotherapy notes to be properly differentiated from progress notes, there are a few things that they aren’t supposed to contain: diagnosis, symptoms, clinical test results, and treatment plans. If your document has any of this information, it will be legally considered a progress note.

So what exactly do psychotherapy notes contain? This is evidently fairly dependent on the encounter that you have with a patient, but the general purpose of a psychotherapy note is to consolidate your own knowledge and memory regarding a specific patient. You may want to record an observation, hypothesis, or generalized notes to help provide context to your treatment and ensure you remember all important details of the patient’s health condition. To help healthcare practitioners write efficient and effective psychotherapy notes, we’ve created a PDF template that can be downloaded and utilized for free.

How to Use This Template for Psychotherapy Note

We know how busy the schedule of a therapist can get, particularly if they typically treat numerous patients. To help ease the work requirements of clinicians, we’ve ensured our psychotherapy note example template is very easy to use, you just need to adhere to the following steps:

Step One: Save the PDF

There is a link to the psychotherapy note template on this page. All you have to do is click on the link and you’ll be taken directly to a PDF version of the document. From here, you can save the PDF onto your computer where it can be printed off or edited electronically, depending on your preference.

Step Two: Make the necessary edits

After you have had an encounter or a session with a patient and you want to write a psychotherapy note, it’s time to edit the document. You can do this electronically (which we recommend) or physically, by printing off a hard copy and handwriting your notes. When the template is ready, simply add the relevant changes.

Step Three: Save and/or store the document securely

Although psychotherapy notes are not technically legal documents, meaning they aren’t designed to be shared among providers, they still need to be stored in a secure way. The method you use to store your psychotherapy notes will depend on whether you’ve written them electronically or physically. Either of these options is fine, as long as you have adequate safeguards in place. The information contained in psychotherapy notes is confidential, so you need to ensure that your patient's privacy is protected at all times.

Who Can Use this Printable Psychotherapy Note Template?

We have created our psychotherapy progress note with a wide range of different therapists in mind to ensure it is as applicable as possible. Some of the types of therapists that will benefit from using our psychotherapy note template include:

• Counselors
• Mental Health Counselors
• Psychologists
• Psychiatrists
• Psychotherapists
• Clinical Social Worker

It is likely that each of these types of clinicians will have their own specializations and techniques when it comes to treating patients. We’ve ensured that the structure and general format of our psychotherapy notes are applicable to all clinicians, regardless of these specific specializations. Further, you will be able to reap the benefits of this template irrespective of how long you’ve been working as a therapist. Trainee therapists who are just learning how to write clinical documentation will find the template extremely useful, as it helps structure information and ensures they are including relevant details. On the other hand, seasoned professionals who have been working as a therapist for years will also benefit from using the template, as they can sharpen up the conciseness of their documents and focus on efficiency and accuracy.

Why is This Template Useful for Psychotherapist?

If you save our psychotherapy note template and implement it into your practice, you will likely find that it has a range of different uses in the day-to-day workflow of your business. These uses include:

• Standardization: Using our psychotherapy note template will guarantee standardization across your clinical documentation. While the specific contents of each psychotherapy note will obviously differ, by using the same format and structure, you can introduce some standardization into your documentation, which will improve readability.
• Saves Time: The amount of time that you will save by using a psychotherapy note template is definitely one of its most useful aspects. You no longer have to structure your own documents or create a brand new page every time you want to write a psychotherapy note, as all of this work has been done for you. Instead, you simply need to access the PDF template we’ve created and edit directly onto the document. ‍
• Efficiency: Every therapy practice is looking for ways they can improve efficiency at their workplace, and our psychotherapy note template is one of the best ways that this can be achieved. As we described, using our template will save you a significant amount of time, which can instead be spent completing more pressing tasks and improving the general productivity at your clinic.

Benefits of Psychotherapy Notes

In addition to having various uses for therapists, our psychotherapy note template will be very advantageous for your therapy practice. Some of these benefits include:

Track your patient’s progress

Although progress notes also serve this function, having accurate and well-structured psychotherapy notes can assist in tracking the progress of a patient. Psychotherapy notes provide therapists with information relevant to a session with a patient, allowing them to compare documents and ascertain how significantly a patient has improved.

Informed clinical decisions

One of the most important aspects of psychotherapy notes is the role they play in ensuring therapists have access to all the information required to make informed clinical decisions. Psychotherapy notes are written by therapists when they don’t want to forget an important detail or conversation that occurred during an encounter with a patient. By recording these details, the therapist increases the likelihood of them making informed clinical decisions when they are treating their patient.

Organization

Using a psychotherapy note template is likely to improve the organization of both your individual work, but also the wider therapist practice that you work at. These templates can be distributed to every therapist working at a business to ensure standardization across the practice. They can also be stored online, meaning that physical storage facilities (which can be hard to keep organized) are no longer required.

Workflow

With the time that is saved by using the psychotherapy note template, you will be able to optimize the workflow at your therapist practice. Practitioners no longer have to design a new document every time they want to write a note, and administrative staff no longer have to chase up physical copies of notes that have gone missing, or been misplaced. With our psychotherapy note template, these processes are simplified and you can use the time you save completing other important tasks.

Improve accuracy

Because psychotherapy notes help consolidate a therapist’s knowledge about their patients, they play a very important role in improving the accuracy of care delivery. The outcome of this improvement is better clinical outcomes – helping patients achieve the care they deserve.