Love working with patients, hate writing therapy notes? You’re not alone. Most health practitioners love helping their patients but dread the paperwork of private practice.
Unfortunately, there’s no getting around creating these standard medical records. Therapy notes are important for monitoring the efficacy of treatments and communicating patient information. They are also essential for the filing of health insurance reimbursement claims.
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While you can’t do away with therapy notes completely, you can use TextExpander to make completing them easier.
Key takeaways
- Therapy notes can’t be skipped, but they can take less time. They track how well treatment works, share client information, and support insurance claims, so the goal is a faster process, not a thinner note.
- Templates do most of the work. SOAP, DAP, BIRP, and PIRP formats all have templates, and adding checkboxes and dropdown lists cuts the searching, typing, and spelling errors in the details that repeat.
- A phrase library keeps notes consistent. Saving intervention words, presentation descriptions, session themes, treatment approaches, and diagnostic codes means you write them once and reuse them in every progress note.
- Templates belong in notes, not psychotherapy notes. TextExpander Snippets hold the repeatable structure and phrasing of a progress note, with fill-ins for client details, while private psychotherapy notes stay separate and client information stays out of the Snippet.
What should be included in a therapy note?
As per the SOAP format, a therapy note should have four components: Subjective, Objective, Assessment, and Plan.
- The Subjective component includes the Chief Complaint (a quote from the patient about what brought them to therapy); the History of Present Illness (the patient’s condition from the initial symptom to the present state); the History (pertinent medical history); and a review of symptoms.
- The Objective component includes information that the therapist or healthcare provider can observe, such as the physical presentation or psychological status.
- The Assessment component is a description of the main symptoms, typically accompanied by a diagnosis (or list of possible diagnoses) and/or possible causes.
- The Plan component is a description of what the health provider will do to treat the patient.
The fastest way to write therapy notes
TextExpander is a shorthand typing tool that lets you summon up words, phrases, and templates with just a couple of keystrokes.
(Read this article: What is TextExpander?)
Using TextExpander, you can create templates for therapy notes and make them appear on any page or platform with minimum typing.
TextExpander has several customization features, so you can create customizable templates. For example, you can add form fields, checkboxes, and dropdown lists to make them even easier to fill out.
TextExpander is also a wonderful tool for storing repetitive codes, terms, and phrases. You can create a library of standard medical terms, phrases, and descriptors on TextExpander to add them to documents without having to fully type them.
Dr. Jeremy Sharp, aka The Testing Psychologist, uses TextExpander to insert diagnostic codes, write results sections, populate recommendations, and sign reports. He created a series of helpful videos to illustrate how he does this — we recommend checking them out!
Write therapy notes faster
Here are some tips for writing therapy notes more quickly.
Use templates for therapy notes
SOAP, BIP, DAP, PIRP, BIRP. No matter what type of therapy progress note you use, there’s a template for it.
And that’s a good thing because templates save you time and eliminate the need for creating records from scratch.
Electronic health record (EHR) software programs usually have options. However, if you do not have EHR software, you can search for templates online, download them, and adapt them to your needs.
In fact, designing your own template might be the best option, because it gives you the flexibility to create the perfect note for your unique needs.
Use a ready-made template or design your own; just don’t waste time typing therapy notes from scratch.
For filled-in SOAP, DAP, and BIRP examples and a step-by-step guide to building your own template, see our guide on how to write progress notes faster.
Use checkboxes and dropdown lists
When creating your own progress note template, or adapting an existing one, be sure to add checkboxes, dropdown menus, and similar features whenever possible.
Having lists of items to select, as opposed to just fill-in-the-blanks form fields, saves you time since it reduces the amount of searching and typing that you need to do.
Lists and menus also have the advantage of preventing spelling errors and freeing you from having to rely on memory to add specific, hard-to-remember information.
Save standard terms, phrases, and descriptors
Repetitive language is standard in therapy notes. For example, “The patient presents symptoms of anxiety and depression” is a phrase you might write in the therapy notes of all patients suffering from anxiety and depression.
Instead of typing these standard terms, phrases, and descriptors from scratch each time, you can type them only once and save them so that you can easily access and use them in the future.
The idea is to create a library of standard phrasing and vocabulary — including intervention words, patient presentation descriptions, themes of sessions, treatment approaches, diagnostic codes, and more — so you can add them to your therapy notes without having to fully type them.
If you do not have software that provides this already, you can create your own lists of frequently-used terms and phrases. Some of these lists are available online — this list of commonly used intervention words for mental health progress notes is an example.
“Progress notes planner”-style books such as this one also provide a comprehensive catalog of health-related terms and descriptions for different types of practices.
Therapy notes vs. psychotherapy notes: what goes where
Progress notes belong in the client’s record and cover what care and billing need: session times, the type of treatment, symptoms, diagnosis, the treatment plan, and progress. Psychotherapy notes are a clinician’s private notes analyzing the session, kept separate from the record, and HIPAA protects them more strictly.
| Detail | Progress notes | Psychotherapy notes |
|---|---|---|
| What they hold | Session start and stop times, modalities and frequency of treatment, medication, test results, diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date | The clinician’s notes documenting or analyzing the conversation in a private counseling session |
| Where they’re kept | In the client’s record, usually your EHR | Separate from the rest of the record |
| Who can see them | Used and shared for treatment, payment, and operations under HIPAA rules | Disclosure generally needs the client’s authorization, even to another provider for treatment, with limited exceptions |
| Good fit for a template? | Yes: the structure, codes, and phrasing repeat from session to session | Rarely: the content is unique to each session |
That split matters for speed: the structured parts of a progress note are the parts you can template. Our mental health SOAP notes show the format, and a Snippet can hold the headings, CPT code options, and standard intervention phrases, with fill-ins for each client’s details.
Keep client information out of the saved Snippet: names, dates of birth, and anything said in session go into fill-ins or straight into your EHR. TextExpander is compliant with the HIPAA Security, Privacy, and Breach Notification rules and signs BAAs for qualified Enterprise customers, but no tool makes a practice HIPAA compliant on its own. See TextExpander and HIPAA for the details.
How do you catch up on therapy notes?
“Start writing your current notes each day and come up with a system for clearing away the backlog. When this happened to me, I wrote a list of which clients had unfinished notes and tackled a few clients each day until I was caught up,” April Snow, LMFT from SensitiveTherapist.com, wrote.
Even if you can’t remember anything from the session, make a note anyway. “It’s best to have a note in the file, even if it’s sketchy. Include the basic information needed for billing: date, the start and stop time, the location of the session, the CPT code, and a general description, like ‘continued to work on progress toward treatment goals.’ This is better than nothing. At the end of the note, include the date of the next session to indicate continuity of care, as well as the date the note was written,” Beth Rontal wrote on the blog Documentation Wizard.
It’s free to try TextExpander
TextExpander saves therapists and other health care professionals hours each month by eliminating the need to type repetitive words, codes, and phrases fully.
Incorporating TextExpander into your workflow will not only help you complete therapy notes faster, but will save you time that you can use to focus on work that really matters to you.
TextExpander is free. Your time isn’t.
Create shortcuts for the things you type most and start saving time everywhere you type. Use it solo or build a shared library with your team.
Free forever, no credit card required.
Frequently asked questions
How long should it take to write therapy notes?
It all depends on how you take your notes, how thorough you need to be, and whether or not you use tools to help you type faster. While some therapists claim to spend between two to five minutes on each progress therapy note, most agree that at least fifteen minutes are necessary to reflect upon a 45-minute session.
How do you write a good mental health progress note?
A good mental health progress note is clear, concise, and professional in tone. One of the easiest ways to write a good mental health progress note is to use the SOAP (Subjective, Objective, Assessment, and Plan) format.
Is it HIPAA compliant to use a text expander for therapy notes?
It can be part of a compliant workflow, but no tool makes a practice HIPAA compliant on its own. TextExpander is compliant with the HIPAA Security, Privacy, and Breach Notification rules, and it signs BAAs only for qualified Enterprise plans. The key rule is that Snippets should not contain PHI. Save the template itself, with its structure, codes, and standard phrasing, and type client names, dates, and session details into fill-ins as you expand the note, so they land in your EHR instead of your Snippet library.
