How to Write Better Clinical Notes
A Guide for Mental and Behavioral Health Therapists
Clinical notes are a bittersweet necessity in mental health work. They support treatment planning, continued care, reimbursement, and legal protection. Yet, they can also be time-consuming, confusing, or anxiety-inducing for clinicians who struggle to write them well. No matter what stage you are as a therapist, this guide will help you write clearer, faster, and better therapy notes.
Why Good Clinical Notes Matter
Clinical notes aren’t just documentation—they’re a form of communication and professional accountability. Well-written notes:
- Provide a clear record of treatment and progress
- Support coordination with other providers
- Ensure ethical and legal compliance
- Facilitate insurance company reimbursement
- Protect you in the case of audits or legal proceedings
Not keeping good documentation or writing unclear notes can harm clients and put clinicians at risk.
When to Write Your Notes
Immediately after sessions is ideal. Writing notes while the session is fresh helps ensure accuracy and detail, and prevents a backlog from building up. If you can’t write them right away, aim to complete all documentation within 24 hours. Procrastination is one of the biggest pitfalls, often leading to rushed, incomplete notes or burnout from piling documentation.
What to Include in Your Notes
Regardless of the format you use, every good therapy note should contain:
- Client presentation: mood, affect, appearance, behavior, and engagement
- Session content: themes discussed, interventions used, and therapeutic goals
- Assessment: your clinical impression, client progress, risks or concerns
- Plan: next steps, homework, referrals, follow-up actions
Make sure your notes are:
- Clear and concise: Avoid jargon or overly flowery language
- Objective where possible: Differentiate between observations and interpretations
- Well-structured: Use a consistent format to improve readability and efficiency
- Free of typos and grammar mistakes: Poor grammar can confuse readers and reduce credibility
Choosing a Format: SOAP, BIRP, or DAP
Let’s break down the most commonly used note formats with pro-tips for each:
1. SOAP Notes (Subjective, Objective, Assessment, Plan)
- S (Subjective): The client’s report of how they feel or what they experienced
- Pro-tip: Use direct quotes sparingly to capture emotional tone
- O (Objective): Your observations during the session (e.g., affect, behavior)
- Pro-tip: Describe behavior specifically, not interpretation (“tearful” not “depressed”)
- A (Assessment): Your clinical assessment or diagnostic impression
- Pro-tip: Connect this section to your treatment goals and interventions
- P (Plan): What you’ll do next (e.g., homework, scheduling, referrals)
- Pro-tip: Document changes to the treatment plan or new risks
2. BIRP Notes (Behavior, Intervention, Response, Plan)
- B (Behavior): Client behavior or report during the session
- Pro-tip: Include specifics on frequency, duration, or intensity
- I (Intervention): Techniques, questions, or tools you used
- Pro-tip: Use clinical language that ties back to your therapeutic modality
- R (Response): How the client responded to your interventions
- Pro-tip: Highlight insights, emotional shifts, or resistance
- P (Plan): Upcoming session focus or therapeutic homework
- Pro-tip: Be consistent in tracking goal progress over time
3. DAP Notes (Data, Assessment, Plan)
- D (Data): A blend of subjective and objective information
- Pro-tip: Structure this like a mini-narrative that reflects the session
- A (Assessment): Your synthesis of the session, client progress, or clinical concerns
- Pro-tip: Consider risks, motivation, and treatment alignment
- P (Plan): Next steps and strategies
- Pro-tip: Keep a running list of recurring patterns to track over time
For a helpful breakdown of note formats, you might enjoy this SOAP vs. DAP vs. BIRP comparison from SimplePractice.
Common Pitfalls to Avoid
- Vagueness: Phrases like “the client is doing better” are too broad. Be specific: “Client reported fewer intrusive thoughts this week, from 5 per day to 2 per day.”
- Over-documenting or under-documenting: Aim for balance in your documentation. Too little documentation can be legally risky, but recording too much wastes time.
- Lack of clinical focus: Write your notes to reflect your client’s therapeutic goals, rather than solely the narrative of the session.
- Repetitive copy-pasting can hinder your work. While templates can help, tailor your behavioral health notes to the session.
- Poor time management: Letting documentation pile up increases errors and stress.
Tools for Writing Better Notes
In today’s digital age, mental health therapists have powerful tools at their fingertips to help streamline documentation.
1. Electronic Health Records (EHRs)
Mental health EHR systems simplify documentation, organize client files, and reduce time spent on administrative tasks. For example, CheckpointEHR offers behavioral health clinicians a more efficient and intuitive experience when logging clinical notes. Through a user-friendly note format, automated claims submission, and highly-adaptable workflows that support Medicaid and insurance requirements.
2. AI-Supported Notes
AI-supported tools are emerging as time-saving solutions for clinicians. Upheal is a secure AI note assistant that transcribes sessions (with consent) and drafts therapy notes using preferred format. This can save hours each week and improve accuracy and consistency.
3. Speech-to-Text Tools
Apps like Quill or other secure, built-in dictation tools allow you to speak your mental health notes out loud and transcribe them instantly. These note dictation platforms can be helpful for mental health professionals who think better verbally than through typing.
4. Note-Taking Templates & Checklists
Develop a set of templates or prompts that match your preferred format. Keeping a checklist for each format (SOAP, BIRP, or DAP) can help ensure you hit all key points without overthinking.
For a more detailed look into streamlining your documentation, this Therapist.com guide to writing progress notes is another excellent resource.
Final Thoughts
Writing long and complicated notes does not inherently mean your notes are better in quality. With clarity, structure, and consistency, your notes can become a helpful tool rather than a dreaded task. Choose a clinical mental health notes format that aligns with your thinking style and avoids common pitfalls. Additionally, take advantage of intuitive clinical tools like CheckpointEHR or Upheal in saving time and reducing administrative burden.
Your documentation is part of your clinical craft—let it reflect the same thoughtfulness and care you bring to your sessions.