From session to note: here's an example
Ever finish a session knowing exactly what happened, but then sit down to write your note and think, “Okay, but what do I actually write?”
Let's walk through an example.
In session:
During session, your client discusses a conflict they had with their partner earlier that week. They describe feeling angry, sad, and confused during the interaction. They share that the conflict reminded them of growing up in a household where their parents frequently fought. As they discuss the experience, they describe anxiety, increased body tension, and what they call “unreasonable anger feelings.”
The therapist:
The therapist used a DBT approach to teach distress tolerance skills, specifically TIPP.
The therapist introduced the window of tolerance model.
Client reported feeling emotionally calmer following the TIPP skills, and they reported increased understanding of their response within the context of the window of tolerance.
So, what might that look like in your note? (Think Data section)
Client attended an individual session in the office and reported a conflict with their partner earlier in the week, during which they experienced anger, sadness, and confusion. Client reflected on how the conflict reminded them of growing up in a household where their parents frequently fought. They identified experiencing anxiety, increased body tension, and what they described as “unreasonable anger feelings” during the interaction. This clinician validated the client’s emotional experience and introduced DBT distress tolerance skills, including TIPP, guiding the client through paced breathing and progressive muscle relaxation. Psychoeducation regarding the window of tolerance was provided to support the client’s understanding of nervous system activation and emotional responses. Client was receptive to the interventions and reported feeling calmer following the skills practice, as well as a greater understanding of their emotional responses in the context of the window of tolerance.
Notice how the note captures more than just what the therapist did. It reflects the client's experience, the clinical work, and how the client responded.
You’re documenting symptoms (think medical necessity), intervention (think treatment goal), and client response (think progress).
You don't need to document every word of the session. The goal is to capture the clinically relevant information clearly and accurately.
If you find yourself getting stuck translating your clinical work into documentation, that's exactly why I created Ok, But What Do I Write? My trauma-informed progress note guide includes DAP and SOAP examples, prompts, and language to help you write notes that reflect the work you're doing.
I hope this makes your next progress note a little easier!
Take care,
Allison
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