Session notes: what to include

Good session notes do two jobs at once: they help you and, where relevant, your colleagues pick up exactly where a client's therapy left off, and they're the record that needs to hold up if AHPRA, a court, or an insurer ever asks to see it. Here's a practical structure that covers both.

Why the structure matters more than the length

Long notes aren't necessarily good notes. What matters is that each entry is clear enough for you — or another registered practitioner, if you're ever unavailable — to understand what happened in the session, what mattered clinically, and what comes next. A consistent structure gets you there faster than a blank page every time.

A practical structure for each session

• Date, duration and format. When the session happened, how long it ran, and whether it was in person or via telehealth.
• Presenting content. What the client raised or worked on in this session, in your own clinical language rather than a verbatim transcript.
• Clinical observations. Mood, affect, risk indicators, and anything else clinically relevant to this session specifically.
• Interventions used. The specific therapeutic techniques or approaches you used, briefly — enough to show your clinical reasoning, not a lecture transcript.
• Risk assessment, where relevant. Any risk indicators raised, how you assessed them, and what action (if any) followed.
• Plan for next session. What you and the client agreed to focus on next, so you're not starting the following session by re-reading the whole file to remember where you left off.

What to leave out

Session notes work best as clinical records, not diaries. Avoid recording personal opinions about the client that aren't clinically relevant, unnecessary detail about third parties who aren't your client, and anything you wouldn't be comfortable having read back to you, the client, or a regulator in a professional context.

Write them close to the session, not days later

Notes written the same day are consistently more accurate than notes reconstructed a week later from memory. Software that lets you write and save notes straight from the appointment — rather than a separate step you do "later" — measurably reduces how often "later" turns into "never."

Notes for couples, families and group work

When you're seeing more than one client in a session, be explicit in your notes about who was present and what's attributable to each person, rather than a single blended account. This matters clinically — you want to be able to track each individual's progress — and it matters for privacy, since each client is generally only entitled to access the parts of a shared record that concern them, not a family member's private disclosures made in the same session.

What happens when a client transfers to another practitioner

If a client moves to another psychologist — whether they're changing practices or simply following a referral pathway — clear, well-structured notes make that handover far smoother, both for continuity of care and for the client, who shouldn't have to re-explain their entire history from scratch. Being able to export a client's record cleanly, with consent, is as much a service to the client as it is an administrative task.

A quick template you can adapt

If you want a starting point rather than a blank page: date, duration, format; presenting content in a sentence or two; mental state or risk observations; the specific intervention or technique used; any risk assessment and action taken; and a one-line plan for next time. Six lines, most sessions — more if something clinically significant happened, never less than that.

Bringing it together

A consistent structure — date and format, presenting content, observations, interventions, risk where relevant, and a plan for next time — covers most of what a good session note needs to do, for you and for anyone who might need to rely on it later. The goal isn't a perfect note every time; it's a consistent one.