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Which format you use is a training decision

Choose the format your training taught you, and a therapy note is drafted from the session or from a recap spoken once the room is empty.
Two questions, neither of them about software.
The formats and the sources it works from.
The usual session formats
Data, assessment and plan; behaviour, intervention, response and plan; and the narrative entries some services prefer.
A recap when a recording is wrong
Where capturing a session is not appropriate, a spoken account afterwards becomes the source.
Different session configurations
Individual, couples, family and group work all produce drafts, and the speaker labels make clear whose contribution is whose.
Material that should stay out
The draft covers what the session addressed. What never belonged in a file is yours to leave out, not ours to invent.
The transcript underneath
Every line can be held up against the session itself, which allows a careful rather than a trusting review.
Output you can file anywhere
The result is plain text, so it goes into whichever system holds the case record without a conversion step in between.

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@tutranscript

Name the format, supply the source, then judge it.
Capture an authorised session, or dictate a short account of it after the client has gone and the room is quiet.
Select the format your profession uses and set how much detail the therapy note should carry for its purpose.
Read the draft, remove anything that does not belong in a record, correct what is inaccurate, and it is yours.
Four settings with different documentation habits.
Harriet Ashworth
Psychotherapist in Private Practice
I use a narrative format, which most note tools cannot handle at all. Here it is one instruction, and what comes back is close enough to my own habit to edit rather than rewrite.
Kwabena Asante
Family Therapist
In a family session the important thing is who said what to whom. Keeping the speakers apart in the therapy note is the only way I can write it honestly.
Solveig Halvorsen
Counselling Service Manager
Our team came from four training backgrounds and wrote four different notes. Naming the format per clinician gave us consistency without imposing one school on everybody.
Marek Zabłocki
Substance Misuse Counsellor
I dictate for three minutes after each client. What comes back is a usable starting point, and I spend my time deciding what should not be in the file.
Formats, sources and where the clinician takes over.
Name the format your training taught, supply the session or a recap, and a therapy note comes back for you to judge.
Draft the Session