Note · private practice
Therapist session notes without an EHR
A lot of solo practices start in a notebook, a locked folder, or six half-finished Google Docs. That works until you cannot find last month’s intervention, or a client asks what you worked on in March. You do not need a clinic EHR on day one. You do need the same five fields, in the same place, every time.
What “good enough” actually is
A note that will still make sense in six months answers five questions: who, when, what you did, what changed, what happens next. If a field is blank because nothing happened, write “none” — empty fields are how notes rot. This is not a legal form and it is not a substitute for the rules of your license or your state. It is a way to stop inventing a new format at 8:40 p.m.
The five fields
- Client + date + length. One line. No narrative here.
- Focus. The thing you actually worked on, in a sentence a colleague could understand. Not the whole history.
- What you did. Intervention, not vibes. “Practiced a 4-count pause before answering partner texts” beats “processed communication.”
- What shifted. Observable, even if small. Affect, a decision, a homework they agreed to. If nothing shifted, write that.
- Next. One concrete follow-up you or they own before the next hour. If there isn’t one, the hour did not close.
Where to keep it
Pick one store and stop opening a second. A locked Notion database, a local encrypted note, or your EHR if you already pay for one. The failure mode is “this session was special so I put it in email.” Special sessions are the ones you will need later. Same database, same properties, every row.
If you use Notion: one Clients database, one Sessions database, relation from session → client. Do not put session text on the client page. You will never find it. Filter Sessions by client when you prep. That is the whole architecture.
Close the hour in five minutes
Write the five fields before you stand up, or in the ten-minute gap you already protect after back-to-backs. Do not “write it up tonight.” Tonight is when you remember the joke and forget the homework. If you cannot fill Next in one line, the session is not finished — name the next step out loud before they leave.
What this is not
This is not HIPAA advice, not a billing code, and not a reason to store more than you must. If you are a covered entity, follow that. If you are deciding whether you even need an EHR yet, a consistent five-field note in one place is the test: can you reconstruct the last four sessions for one client in under two minutes? If yes, you can stay light. If no, the problem is the system, not your memory.
If you want those five fields already wired to clients, billing, treatment plans, and CEUs, that is Therapist Practice OS. The five fields work in a notebook.
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