Writing Clinical Notes
Clinical notes are a record of what happened in a session — kept in the client’s profile for reference. You can write them free-form or use a template to keep your documentation structured and consistent.
Where to Write a Note
There are two ways to start a session note:
Option A — From the client’s profile:
- Go to Clients in the sidebar
- Open the client’s profile
- Click the Notes tab
- Click + New Note
Option B — From a calendar appointment:
- Click the appointment on your calendar
- In the details panel, click Add Note (or Add Session Note)
- This opens the note editor pre-linked to that appointment
[Screenshot: “Add Note” button on the appointment details panel]
The Note Editor
The note editor has two parts:
1. Note Details
At the top of the editor, fill in:
- Title — A short label for this note (e.g., “Session 12 – Progress Review”)
2. Note Content
The main writing area uses a rich text editor where you can:
- Type freely or paste from another source
- Apply formatting: bold, italic, headings, bullet lists, tables
- Use checkboxes for structured review items
[Screenshot: Full note editor with title field and rich text editing area]
Using a Template
Starting a note from a template gives you a pre-built structure to fill in:
Open a New Note
From the client’s Notes tab, click + New Note.
Choose a Template (Optional)
If prompted, select a template from the dropdown. The editor will be pre-filled with the template’s structure.
Alternatively, you can type directly in the editor without using a template.
Fill In the Content
Replace the placeholder sections with your session-specific observations, goals, interventions, and outcomes.
Save the Note
Click Save when you’re done. The note is stored in the client’s profile.
If you write notes in a consistent format, consider creating a template that matches your preferred structure. It only takes a few minutes to set up and saves time on every note afterwards.
Editing a Note
- Go to the client’s Notes tab
- Find the note you want to edit
- Click the Edit icon (pencil)
- Make your changes
- Click Save
Note Visibility
Session notes are private — only you (the therapist) can see them. Clients cannot view your clinical notes, even in their client portal.
Notes are distinct from tasks and documents — those can be shared with clients. Clinical notes remain strictly on your side.
Notes Linked to Appointments
When you write a note from an appointment, the note is automatically linked to that specific session. This makes it easy to review what was discussed in each appointment when you look back at the client’s history.
You can also write notes independently of any specific appointment — useful for phone check-ins, case review notes, or supervision records.
Tips for Effective Session Documentation
- Write notes soon after the session — details are freshest when the session is still recent
- Use consistent structure — this makes it easy to spot progress over time
- Keep notes factual and objective — document observations, interventions, and client responses
- Review past notes before each session — a quick read before the client arrives helps you pick up where you left off