A session note (or progress note) helps track client progress and treatment in a standardized format. These notes also facilitate care coordination when shared with other providers.

Because session notes are part of a client's medical record, they should be:

• Culturally sensitive and free of moral judgment
• Precise and objective, avoiding absolutes like “always” or “never”
• Clear and professional, avoiding ambiguous phrases like “I think” or “it seems”
• Accurate, using quotation marks when directly quoting a client

When to Record a Session Note

• Only document sessions that took place. If a session did not occur, select “No” under Did the session happen? and indicate the reason.
• You are only paid for sessions that have a completed session note.
• Edits can be made for a short time after submission.
• Enter notes within 72 hours of a session to maintain accuracy, ensure proper documentation for crisis management, support care coordination, and comply with regulatory standards.

Recommended Format: SOAP Notes

While you may use any format, the SOAP (Subjective, Objective, Assessment, Plan) note template is widely recognized and structured.

S - Subjective

Client’s experiences, observations, and statements during the session.
Example: “Client reports that they have been unable to focus at school.”

• Client’s self-reported thoughts, emotions, and concerns
• Direct quotes
• General content and process of the session
• Reported changes in symptoms or condition

O - Objective

Observable data that supports the subjective report.
Example: “Client appeared well-groomed and calm.”

• Symptoms (observed or reported)
• Client’s appearance, presentation, mood, and affect
• Relevant observations about behavior or physiological responses

A - Assessment

Your clinical impression of the client’s progress and overall session evaluation.
Example: “Client appears to understand the new goal.”

• Analysis of mood, risk of harm, orientation, and engagement
• Rationale for diagnoses and interventions
• Client’s response to treatment and progress toward goals

P - Plan

Next steps, recommendations, and follow-up care.
Example: “Client will take a 20-minute walk daily and return to therapy next week.”

• Plan for next session
• Homework assignments
• Modalities, interventions, or techniques used
• Referrals to specialists, if applicable

Following these documentation guidelines ensures clarity, consistency, and compliance while supporting effective client care.