Patient Notes Template

Patient notes template

Authored by Dr. Hannah Lin, a counseling psychologist trained in CBT, ACT, and IFS. Her clinical interest is modality fit: when to switch a framework, and when to stay.

Educational content for licensed clinicians. Not clinical, legal, billing, or licensure advice. Adapt every note to the person in front of you, your board, your facility, and the payer policy that actually governs the visit.

Use this patient notes template when the chart does not name a format. A covering clinician should be able to answer five questions from the page: why they came, what you saw, what you did, how they used it, and what happens next. If you need one patient note template for today’s visit, fill those same seven lines and sign.

I stay with the seven lines when nothing in the chart, the program manual, or the payer’s written policy names SOAP, DAP, or BIRP. I switch when one of those does. A format does not make the hour more clinical. It only changes where the same facts sit.

When to switch

Format	Switch when	Keep separate
SOAP	Words must split from what you saw	Subjective and Objective
DAP	Words and observations stay one block	Data, then Assessment
BIRP	A counted behavior must stay apart from the technique	Behavior and Intervention

SOAP

Section: SOAP

What to write: Move the patient’s words and the clinical focus into Subjective. Move appearance, affect, behavior, and reported symptoms into Objective. Put your working impression in Assessment. Put the next step in Plan. Sign in the chart’s signature field.

Filled example: Subjective holds “I almost canceled the review again” and the cancel-urge. Objective holds the coat, the speech rate, the short sleep, and no panic attacks. Assessment names the freeze thought as the target. Plan keeps the October 21 visit and the morning thought record.

Use the SOAP notes guide when you need the four boxes in full. Do not invent a Subjective and an Objective split if your chart has one narrative field. Splitting for its own sake makes the next clinician hunt.

DAP

Section: DAP

What to write: Keep the reason and the observations together as Data. Assessment is your impression, not a second copy of the story. Plan is the next step, the between-session task, and any risk follow-up.

Filled example: Data holds the cancel-urge, the coat, the speech, and the two short nights. Assessment: freeze thought is still driving the urge to leave, and a three-minute defusion was usable in the room. Plan is unchanged from the seven-line note.

DAP fits when you refuse to pretend that what they said and what you saw are different documents. It does not fit a medical chart that has already built Subjective and Objective as separate fields.

BIRP

Section: BIRP

What to write: Put the counted behavior in Behavior: how often, how long, or what you saw them do. Put the named technique in Intervention. Put how they used it in Response. Put the next step in Plan.

Filled example: Behavior: one cancel-urge before a review, two nights of short sleep, no panic attacks. Intervention: CBT thought record plus one three-minute ACT defusion. Response: stayed seated and renamed the urge. Plan: one thought record the morning of the review.

I switch to BIRP when a program is counting a behavior and will not read a story. Missed work days, panic exits, or substance use on a target list belong in Behavior as a count. I do not switch to BIRP for an ordinary outpatient hour whose useful record is the story plus one technique.

Blank SOAP, DAP, and BIRP skeletons, with the format choice beside them, are in progress note templates and examples.

Copy the blank lines

If the hour needs a dedicated risk field, a treatment-plan link, and a sign-off check, use the session note template for behavioral health. Stay with these seven lines when you need the short visit record and no format is named.

What stays out of the chart

Keep your hypothesis, your countertransference, and your analysis of the conversation in a separate psychotherapy note if you keep one. 45 C.F.R. § 164.501 defines psychotherapy notes as notes recorded, in any medium, by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. The same definition excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. That exclusion is the category line. It does not say those items belong on this seven-line note. I write only the excluded items this visit produced, and I keep the analysis of the conversation off the chart.

If you are unsure which sentence is chart and which is process, read process notes versus progress notes before you paste a supervision thought into the visit record.

What these lines do not decide

The seven lines can hold a reason, findings, a next step, a date, and your identity. They do not choose a code.

A medication-management visit is a different note. Interval history, current medications and adherence, side effects, mental status, risk, the medication decision, and follow-up do not fit these seven lines. Use the psychiatry notes skeleton for that hour. The same PDF prints both skeletons, one visit per page.

Name the move

The intervention line is where modality fit shows up on the chart. Write the move you actually used.

• CBT: name the thought and the record, the exposure, or the behavioral experiment. “Explored cognitions” is not a thought record.
• ACT: name the defusion, the values step, or the willingness rep, and how long they stayed with it.
• IFS: name the target part and whether you unblended, got permission, or stopped because the system was not ready.
• Coordination: name who you called and what changed in the plan. A voicemail with no content is not an intervention.

If you used two frameworks in one hour, write both, in the order you used them, and write the response to each. The October 14 example does that: a thought record, then a three-minute defusion, then a response that belongs to the defusion rather than to the record.

If you want a draft of these seven lines to edit before you sign, AI clinical notes can start the skeleton. You still choose the framework, you still cut anything you did not do, and you still sign.

Download the note skeletons

The PDF holds this patient notes template on page one. Page two is the psychiatry medication-visit note, for the hour this skeleton does not cover. Fill one page. Sign it. Do not mix the two visits onto one sheet.

References

• Code of Federal Regulations. (2024). Definitions, 45 C.F.R. § 164.501.