Should you be summoned into a court case you will want to organize your notes in the following manner. Note that your case notes belong to you, and do not relinquish them to a lawyer without a court order or a signed client request.

Organization of Legal Notes: Keep each session on a separate page. Do not present run-on notes. Write your signature for every session as the bottom of your notes. If you edit your notes later, circle your edit and initial all changes.

This is how I write my client notes:

At the top: Name of client, date and cost of session. (You can write a session summary at the top for easy reference as well.)

1. Treatment Issue

2. Therapy Goals

3. Progress Towards Goals

4. Homework

5. Treatment Plan

Keep in mind:

~ Client notes are legal documents that provide rationale for treatment and documentation of quality care.

~ Client notes record what worked, what didn't and why.

~ There is some degree of legal protection from liability for counsellors by demonstrating planning and rationale.

~ Case notes establish that the counsellor conducted themselves competently and professionally.

~ Written records are the only concrete proof regarding client treatment and therapeutic progress.

The Association of Counselling Therapists of Canada recommends you take SOAP notes. The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. 

COUNSELLING SESSION SUMMARY NOTES (SOAP Notes) 

Counsellor:  _______________________ Session Date:  _______________ Time:  _____

Client(s) Name:  ________________________________________________

Session #: ______

Subjective Complaint:

Objective Findings:

Assessment of Progress:

Plans for Next Session:

Needs for Supervision:

GUIDE TO SOAP NOTES

Subjective Complaint: Presenting problem(s) or issue(s) from the client’s point of view.  What the client says about causes, duration, and seriousness of issue(s).  If the client has more than one concern, rank them based on client’s perception of their importance.

Objective Finding: Counsellor’s observation of the client’s behaviour during the session.  Verbal and nonverbal, including eye contact, voice tone and volume, body posture.  Especially note any changes and when they occur (such as a client who becomes restless in discussing a topic or whose face turns red under certain circumstances).  Note discrepancies in behaviour.

Assessment of Progress: Counsellor’s view of the client, beyond what the client said or did.  Continual evaluation of client in terms of emotions, cognitions, and behaviour.  Identification of themes and patterns in what client says and does.  Use of developmental (Erikson, social learning theory) or mental health models (DSM-IV).  Include your hypotheses, interpretations, and conceptualization of client.

Plans for Next Session: Plans for client, not for the counsellor.  Short and long-term goals.  How you want to interact with client; what you may plan to respond to in next session with client (follow-up on family issues discussed).  Do you plan to help client focus on thoughts, feelings, or behaviours?  What particular strategy or theoretical approach might you use?  What do you base your plan on?

Plans for Counsellor: What reading or research do you need to do in preparation?  Practice?  What help do you need from your supervisor?