Charting Therapy Notes

A Simple Guide of Charting Therapy Notes 

Many mental health providers enter the field with limited or no formal training on how to document therapy sessions or manage service records effectively. This gap often stems from a lack of emphasis on these practical skills during graduate education, where the focus is placed more on theoretical models and medication management.

Improving training in documentation and services management can enhance the quality of mental health care by fostering better client outcomes, ensuring compliance, and supporting providers in their professional responsibilities. Here’s a simple process and key points for starting and managing therapy notes despite the challenges:

Step 1: The Intake

  • Conduct the therapy intake like a regular psych intake to gather comprehensive information without getting overwhelm. Some people may switch to a different format for therapy (there are no wrong answers) -but it’s not guaranteed if or when you’ll start prescribing medications, so this method makes it easier to switch into prescribing mode, while continuing therapy services.
  • Using a regular psych intake also helps establish direction, limits rambling, and keep the appointment organized.
  • Save the additional talk-therapy questions for the follow-ups, e.g. detailed trauma history, etc.

FYI: don’t blindsight the patient with discussing past trauma issues at that moment and don’t get side tracked at the intake or any session- plan trauma sessions, like in 1-2 months, for example so the patient can prepare and/or the mood is more regulated.

Step 2: The Added Documentation

Include additional sections at the end of the (regular) intake or for the follow-up session, ask about:

  • Triggers: Identify fears or phobias and what is the response. Sometimes you have to give the patient examples,  e.g. small spaces, large crowds, driving, loud noises, bugs, etc. Sometimes it’s not obvious -rejection, confrontation, cultural, etc. note the responses to the trigger – do you avoid school?, driving?, do you feel numb?, etc. 
  • Coping Skills: How do they deal with triggers or manage them? -and I’ll ask how have they worked on these issues in the past or what didn’t work. The patient may say e.g.  journaling, deep breathing, taking walks, etc. Also note the BAD coping skills e.g. ETOH, smoking, eating, gambling, shopping, etc.
  • Goals: even if the patient doesn’t have a formal goal, I usually address/discuss what we should be working on… -improve coping skills, mood management/stability, decrease psych symptoms, stress management, improve QOL/ADLS, etc.
  • Hobbies: To make the conversation lighter, I usually ask what the person does for fun e.g. videogames, playing with the pet, going to the gym, spending time with family/friends, listening to music, TV, reading, etc. and ask about what kind of books, music, media, that interests them.. You’ll be surprised how many people watching crime shows then get paranoid and smoke marijuana to calm down, but get more paranoid…so sometimes they need insight into how their activities may be the root of the problem, making them triggered, or to at least consider taking a break. Sidebar -some people would tell me their hobby is drinking… so whether they think it’s a problem or not, I label bad habits as a lack of coping skills because “hobbies” shouldn’t lead to criminal records, deaths, diseases, etc. but habits can and educating about ETOH or limiting it should frequently be addressed. 
  • Main Support: Understand the patient’s support system and its implications. This mainly affects older populations and/or special needs. You want to know who to contact or in charge in case of emergencies. I have patients who have no one and it can be difficult because sometimes I have to advocate for assisted living, or sometimes my appointments are simply wellness checks. For young people, it’s usually the parents, friends, etc., but in general, a lack of social support (whether younger or older patients) also means how improving the patient’s coping skills and the goals are imperative.

Step 3: Encourage Journaling

  • Suggest journaling as homework to track moods, thoughts, and progress.
  • Frame journaling as a stress management tool and a way to process negative thoughts constructively. The brain works by connections, so if you have an addiction or a 20-plus-year/chronic connection, the only way you can change negative thought processes like guilt and shame is to counter it with positive engagement. Some will still ask what’s the point and I usually respond so we can track your mood and thoughts, to see what’s helpful/unhelpful, etc. I also mentioned how it doesn’t have to be like dear diary novel or a dissertation… I tell them they can write a sentence, a word, draw, etc.

Step 4: Address Noncompliance

  • Build rapport and maintain a supportive, nonjudgmental approach. The patient came back into your office, they didn’t get a journal or they did and didn’t write anything and sat in the chair like a deer in headlights. Well, continue to improve the rapport and let them know it’s okay. Humans don’t change on the snap of your finger. I had an older patient who just made up her own assignments, and brought me a comic strip, and we just laughed because I thought they didn’t make those anymore so it was a light-hearted. I had a younger patient who really lacked motivation and didn’t want to do anything, and sometimes I would remind the patient about medications, but he had issues with that as well so I recommended they seek help elsewhere. At the end of the day, the terms are on the patient and what they ultimately want to do. Don’t work harder than the patient. THEY need to do the work in order to change.
  • Document the lack of compliance/progress while focusing on the coping skills, goals, or utilizing other resources.

Step 5: The Therapy Notes

Still do a regular HPI! here’s an example:  

  • Current HPI: Pt. decided to reconsider med management and agreed to start escitalopram 5mg QAM for increase moods, anxiety, discussed common side effects. No issues with sleep or appetite/or document the regular psych ROS…
  • Psych ROS (Review of Systems): I usually put the ROS under the most current HPI
  • Prior HPI: Pt. declined medication at this time (what happen at the prior session/intake)
  • Any Other Updates/Changes: patient recent lab work was unremarkable
  • MED/SURG: denies, past history of asthma
  • Allergies: NKDA
  • PFSH: patient lives by self, dog, works 9-5 at the Vet Clinic, in an off/on relationship -feels safe, pending college in 2 months. Family is local.

For CPT coding use 99213 + therapy code (90834), if medications weren’t used, ONLY use -90837… Regardless of the codes… You need a HPI with EVERY note.

I rarely use 99214, but it usually applies for community mental health or populations with a higher acuity of care, in which you probably should refer the patient for therapy, instead having a high volume of high acuity patients with medication AND therapy services. It’s not ideal, note how psychiatrists don’t manage their care like that… so a nurse practitioner will easily get more overwhelmed and questioned… For private practice -I mainly use 99213 with therapy.

  • Document the therapy session as a conversation, noting what helps, life changes, and coping strategies.
  • I type during the session for time efficiency, but do what consistently works best for you. Sidebar -I don’t recommend using AI, but it can assist in some situations …. It’s too vague or generic to be helpful for me and I’m not sure about the privacy/legalities. I heard it helps others, but for security measures, don’t use actual names, consider simply using initials or just the term client/patient and avoid financial or super sensitive information.
  • End the note with follow-up plans or assigned homework. If you repeatedly do steps 1-5, it’s actually gets easier to keep up or follow the conversation while typing (so it gets easier with time) and end the note with when the person will RTC (return to clinic) e.g. <4 weeks and/or the homework if applicable.

Step 6: What is the homework?

It depends on the situation but here’s a general list of examples that a journal is helpful for:

  • Self-Affirmation: Encouraging patients to write positive reflections about themselves is crucial for boosting confidence and self-esteem. The goal is to inspire more than surface-level effort, fostering deeper self-awareness and personal growth.
  • Addressing Painful Incidents: Writing about troubling events, particularly those tied to PTSD, trauma, or recurring intrusive thoughts, empowers individuals to process emotions, reduce guilt and shame, and gain a more objective perspective. This helps mitigate feelings of powerlessness and cultivates emotional stability. I usually try to have the patient write it out before discussing, so they can view the issue more objectively and to not blind sight them or to better prepare them to speak about past trauma, and agree about the best time to have the session. You want the patient to feel empowered and not make them speak about it when they’re not ready.
  • Expressive Letter Writing: Creating letters for individuals no longer in their lives—whether for reconciliation, closure, or stress relief—acts as a therapeutic outlet for pent-up emotions and unspoken thoughts.
  • Mapping a Healing Process: Encouraging patients to explore and articulate how they’ve managed challenging emotions in the past—such as forgiveness, anger, or resentment—helps develop actionable strategies for the present and future. This promotes personal accountability and rational problem-solving.

Overall, therapy approaches should emphasizes empowerment/independence, emotional regulation, building coping strategies, managing negative patterns, and having a healthier responses to life’s challenges past and present.

With the above tips, it should start a decent foundation, and below are some downloads and resources. Sometimes, I start with something simple such as writing a list of triggers, because something additional may be more frustrating to the patient so it depends on the situation. Worksheets may assist but can take the hard work out of the patient doing it on their own, so it’s pros and cons to every approach.

Nevertheless, I’ve used worksheets, rating scales, and other formats that has been super helpful. Lastly, I’ve had people who wanted more formal therapies and I refer accordingly -let your practice/care mainly focus on medication management. Therefore, again complete a HPI with every note because some providers don’t and wonder why they’re not getting their care covered…

Additional Links and Resources

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