Writing a session note

Created by Colette Kelly, Modified on Tue, 27 Oct at 10:20 AM by Colette Kelly

At a Glance

Session notes are written on the client's own record, and once saved they cannot be edited, so it is worth knowing what the form asks for before you start. This is the route from the client record. If you have just marked a session attended, you can write the note straight from there instead.

How to do it

  1. From Your Clients, open the client and find the Session Notes section, which shows the number of notes you have written in brackets. Click Add Note and the form opens below the heading. On a brand new client that is the only button you will see; See Notes appears once you have saved your first one.
  2. Set the Session Date. Session Duration (Optional) offers 20 minutes through to 90, with Other for anything that does not fit, and Session Number (Optional) takes a plain number. Both can be left empty.
  3. Choose your Note Template, and do this before you start writing. Six come built in: Free-form Notes, SOAP, DAP, BIRP, Narrative/Process Notes and EAP (Employee Assistance Programme). The structured ones lay out their own headings for you to write into. Any template you have made yourself appears in the same list, below these.
  4. Write the note, then click Save Session Note. The button reads Adding... while it works and confirms with Session note added successfully. That confirmation is your signal it has saved.

Worth knowing: Changing the template after you have written something clears what you have typed. TherapyLock asks first, with Keep writing and Change template, and notes you have already saved are never affected. Choosing the template at step 3 rather than part-way through step 4 avoids it entirely.

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