How to Create a Clinical Note: Step-by-Step Guide
Write structured therapy notes in minutes. Choose from SOAP, DAP, BIRP, and 12 other clinical note formats. Step-by-step guide for therapists and clinicians.
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Creating a clinical note in WellNotes takes three steps: enter your session observations, choose a note template, and generate. The Note Editor accepts free-form text or voice dictation and produces structured documentation in formats like SOAP, DAP, BIRP, GIRP, and more. That can cut documentation time compared to writing every note by hand.
How do you create a clinical note?
- 1
Open the Note Editor
From the Notes dashboard, click "New Note" (the + button). The editor opens in a focused, distraction-free view.
- 2
Enter your session observations
In the large text area, type brief notes from your session. Include key topics discussed, interventions used, client responses, mood observations, and any plan items. You don't need to use any specific format. Write naturally.
- 3
Choose a note template
Select the format that matches your documentation requirements: SOAP, DAP, BIRP, GIRP, SIRP, PIE, Treatment Plan, Intake Assessment, Risk Assessment, Child & Family Therapy, Couples Therapy, Addiction Counseling, Group Therapy, Family Therapy, or Clinical Supervision. The template determines the section structure of your output.
- 4
Adjust note style (optional)
In the Note Style section, choose a tone (Standard, Empathetic, Brief, or Comprehensive) and a length (Short, about 150 words; Medium, about 300; or Long, about 500). Open "Advanced options" to set distribution (Front-loaded, Balanced, or Back-loaded). To keep these as your default for this note type, open "Advanced options" and click "Save as Default". Defaults are saved in this browser and cleared when you log out.
- 5
Generate the note
Click "Generate Note". Within seconds, WellNotes produces a complete, structured clinical note based on your observations and the selected template.
- 6
Review and edit
The note is saved when it is generated and opens for review. Make any manual edits directly in the text, then click "Save Without AI" to keep them, or "Regenerate with AI" to generate it again. The note appears on your dashboard and is saved in this browser. Copy or export it to your EHR before you log out, because logging out clears saved notes from the browser.
What tips save time?
- More detail in your observations = a higher-quality output note. Aim for 3–6 sentences minimum.
- Mention specific interventions by name (e.g., "used CBT thought challenging", "practiced DBT distress tolerance") for clinically precise notes.
- You can edit any part of the generated note after it is generated. The note is already saved, and "Save Without AI" keeps your edits.
Frequently asked questions
Can I edit a note after saving it?
Yes. From the dashboard, click the Edit icon on any note to reopen it in the editor. You can revise the text and save again.
How many notes can I create?
Your first WellNotes subscription starts with a 3-day free trial. One free trial per person and per card. If you have had a WellNotes trial or subscription before, your paid plan starts at checkout. If your card has already been used for a WellNotes trial, no trial starts and you are not charged, and you can then subscribe without a trial. Starter plan users can create up to 50 notes per month, and Professional plan users have unlimited note creation. See the Pricing page for details.
Are my session observations stored?
Not on our servers. Your raw observations (the input text) are only used to generate the note and are not kept on our servers. If you select a client, short excerpts from up to three of that client's earlier saved notes are sent along with them so the new note reflects session history; these are also used only to generate the note and are not kept. While you are writing, an unsaved draft is kept in your browser so you can pick up where you left off; it is removed when you save the note, all drafts are cleared when you log out or your session ends (including the automatic sign-out after 15 minutes of inactivity), and any other draft is discarded after 24 hours. Only the final formatted note is saved, in your browser.
How long does it take to write a therapy progress note?
With WellNotes, you can complete a full progress note in minutes. Writing the same note from scratch usually takes longer. Voice dictation can make it even faster: just speak your observations and generate.
Can I use WellNotes for different clients with different note formats?
Yes. You choose the template each time you create a note, so you can use SOAP for one client and DAP for another. Style (tone, length) can be adjusted for each note, and you can save your choices as the default for a note type with "Save as Default" under "Advanced options".
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