40 Best Therapy Note Templates

1. Standardize structure and fields
Use a consistent framework (eg SOAP or DAP), including session date, client identifier, presenting issue, goals, interventions, progress, and next steps. This improves readability, supports continuity of care, and eases data extraction for outcomes tracking.

2. Protect privacy and comply with regulations
Incorporate de-identified codes where possible, secure storage, access logs, and consent documentation. Ensure notes meet HIPAA or applicable privacy regulations and are only accessible to authorized personnel.

3. Use objective language and clinical relevance
Document observable behaviors, statements, and measurable progress toward goals. Avoid speculation or subjective judgments; clearly link every entry to treatment plans and planned interventions.