Therapy Notes for Therapists, Done Between Sessions
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Most therapists document each session as a progress note in SOAP, DAP or BIRP format, plus an intake assessment and a treatment plan that the progress notes refer back to. WellNotes drafts those notes from a few typed or dictated sentences, so you review and sign instead of writing from a blank page.
Stop spending evenings catching up on progress notes. Type or dictate a quick summary and get a complete note, structured and ready to review.
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Where Do Therapists Lose Time on Documentation?
Spending 1-2 hours after your last session writing notes instead of being present with family
Falling behind on documentation and scrambling before audits or insurance reviews
Struggling to recall session details when writing notes hours or days later
Maintaining the "golden thread": connecting diagnosis, treatment plan goals, interventions, and progress in every single note for insurance review
Which Note Formats Do Therapists Use, and Why?
Outpatient psychotherapy runs on three documents: the intake, the treatment plan and the progress note. The progress note format is usually a clinic or personal preference, not a legal requirement.
SOAP
The most widely recognized structure. Separating what the client reported (Subjective) from what you observed (Objective) makes it easy for a reviewer to see the clinical basis for your assessment.
SOAP Notes template and examplesDAP
Folds subjective and objective material into one Data section. Popular with talk therapists whose sessions are mostly verbal and who find the S and O split artificial.
DAP Notes template and examplesBIRP
Leads with the presenting behavior and names the intervention explicitly, which suits CBT, DBT skills work and any setting where payers ask what you did, not only what you discussed.
BIRP Notes template and examplesTreatment plan and intake
The plan sets measurable goals. Each progress note should show which goal the session addressed, often called the golden thread from diagnosis to plan to note.
Treatment Plan template and examplesAlso useful: Intake Assessment, Risk Assessment.
What Are the Documentation Requirements for Therapists?
Record-keeping duties for licensed therapists come from your licensing board, your payers and your employer. They overlap but are not identical, so check all three.
Retention periods set by your board
Most state boards set a minimum number of years to keep records after the last session, and a longer period for minors. The number differs by state and profession, so confirm it with your own board rather than relying on a general rule.
Medical necessity for insurance
When you bill insurance, each note generally needs the date, start and stop times or total time, the service provided, the intervention used, the client response and how the session relates to a diagnosis and treatment goal. Time matters for choosing between 90832, 90834 and 90837.
Progress notes versus psychotherapy notes
Federal privacy rules treat process notes kept separately from the record differently from progress notes in the chart. Keep the clinical record factual and concise, and keep personal impressions out of it unless they support care.
Timeliness
Many payers and agencies expect notes to be completed within a set number of hours or days after the session. Writing them while the session is fresh also makes them more accurate.
General information, not legal or billing advice. Requirements vary by state, payer and employer; check your licensing board, payer contracts and agency policy.
Example: Fictional DAP note, individual CBT session
Invented example. Client "J.M.", 34, session 6 for generalized anxiety.
Data
J.M. reported sleeping about 5 hours on most nights and rated worry at 7/10, down from 8/10 last week. Completed 4 of 7 thought records. Speech normal in rate, affect anxious but reactive, engaged throughout the 53-minute session.
Assessment
Partial progress toward Goal 1 (reduce worry to 4/10). Thought records show catastrophic predictions about work performance; client identified two alternative explanations with prompting. No safety concerns reported or observed.
Plan
Continue weekly CBT. Introduce scheduled worry time. Client to complete daily thought records and bring them to the next session in one week.
How Does WellNotes Work for Therapists?
Jot Down Key Observations
Between sessions, type or voice-dictate a few sentences about what happened, presenting concerns, interventions used, and client responses. No special formatting needed.
Get a Structured Clinical Note
WellNotes organizes your observations into the format you choose (SOAP, DAP, BIRP, or any of 15 formats) with proper clinical language and section headings.
Review, Sign, and Move On
Read through the generated note, make any adjustments, and export to your EHR. Your documentation is done before your next client arrives.
What Free Resources Help Therapists?
CPT codes you may bill
- CPT 90791: Psychiatric Diagnostic Evaluation
- CPT 90832: Individual Psychotherapy, 16-37 minutes
- CPT 90834: Individual Psychotherapy, 38-52 minutes
- CPT 90837: Individual Psychotherapy, 53+ minutes
- CPT 90839: Psychotherapy for Crisis, First 60 minutes
- All behavioral health CPT codes
- Mental health ICD-10 codes
Free note generators
Generate one note a day from brief, de-identified session details. No account needed.
Comparing tools? Mentalyc alternatives · Upheal alternatives · TherapyNotes alternatives · SimplePractice alternatives
I used to stay an hour after my last session every day just to finish notes. Now I dictate a quick summary between clients and my SOAP notes are done. I've gotten my evenings back.
Dr. Sarah M.
Licensed Psychologist, Private Practice
How Much Does WellNotes Cost, and Where Are Notes Stored?
Starter
$27/mo
50 notes per month, all 15 formats
Professional
$38/mo
Unlimited notes and custom templates
- Your first subscription starts with a 3-day free trial (card on file); voice dictation unlocks when your paid plan starts.
- PDF and CSV export, or copy into any EHR.
- Saved notes stay in your own browser, not on our servers, and are cleared when you log out, so export them first.
Therapists: Frequently Asked Questions
Which progress note format should a therapist use?
Use the format your clinic or payer requires. If you choose freely, SOAP is the most widely recognized, DAP is quicker for talk-based sessions and BIRP highlights interventions. Pick one and use it consistently so your record is easy to review.
How long should a therapy progress note be?
Long enough to show what happened, what you did, how the client responded and what comes next. For a routine session that is often 150 to 300 words. Length matters less than linking the session to a treatment goal.
Can I use WellNotes alongside my EHR?
Yes. WellNotes is a documentation tool, not an EHR. Copy the finished note into your EHR or export it as PDF or CSV. Notes are kept only in your browser, so move them into your record system before you log out.
Does WellNotes pick my CPT code?
No. WellNotes drafts the note. You choose the code based on the service and the time you spent. The free CPT code reference explains the time ranges for 90832, 90834 and 90837.