Session notes: what to include

Good session notes serve two audiences at once: future you, picking up where you left off, and anyone who might reasonably need to review the record — a colleague covering for you, an insurer, or the New Zealand Psychologists Board, if it ever came to that. A consistent structure makes both jobs easier, and it doesn't need to take longer than the looser version you're probably writing now.

A practical structure

• Date, duration and format. When the session happened, how long it ran, and whether it was in person, by video or by phone.
• Presenting content. What the client brought to the session, in your own clinical language — not a verbatim transcript, but enough that the thread is clear later.
• Clinical observations. Mood, affect, risk indicators and anything else clinically relevant you noticed, distinct from what the client reported.
• Interventions used. What you actually did in the session — a technique, a piece of psychoeducation, a specific exercise — not just that "therapy happened".
• Risk assessment, where relevant. If risk was assessed, even briefly, note that it was, and what you concluded — silence on this point is harder to defend later than a brief note that you considered it.
• Plan and next steps. What you're picking up next time, and any homework or between-session tasks agreed with the client.

Why the structure matters beyond the session itself

Clinical records are part of what registration and professional accountability rest on — if a complaint or query ever arose, a clear, contemporaneous record is your best evidence that care was appropriate and considered. It also matters for the more mundane reason that memory fades: a note written in the moment beats trying to reconstruct a session's substance six months later.

What to leave out

Notes work better when they're clinically relevant and reasonably concise, not a blow-by-blow transcript. Avoid recording identifying details about third parties who aren't your client unless clinically necessary, and be mindful that anything you write is, in principle, something the client could request access to under the Privacy Act 2020 — write as though they might read it, because they're entitled to ask.

Keeping notes organised, not just written

A note that exists only in a paper folder or a personal document on your laptop is a liability if it's lost, and hard to search when you actually need it. Structured, digital, backed-up notes — attached to the right client record, dated, and quick to find — do more for you day to day than a well-written note that's hard to locate six months later.