Client Notes for Therapists: What to Write (and Why It Matters)

Good therapy client notes protect both therapist and client. Here’s what to record, how detailed your notes should be, and how to keep them professional and secure.

What do Therapists Write in Their Notes?

The CNHC (2024) say your client record as a whole should include:

• personal data and record of consent (tips on this part HERE)
• any correspondence with or about the client
• your case history (tips on this part HERE)
• your initial therapy plan along with any amendments made as you go along, and the reasons for them
• any re-assessment of the client’s needs or goals
• the care you provided
• any advice given, either verbally or by way of leaflets etc

Some information is collected via your intake form, which stays with your session notes. The rest should be in your client notes and added to each time you see or have contact with the client. It might surprise you to know that there are formal guidelines for recording your session notes if you choose to use them. These are, I think, more familiar to counsellors than hypnotherapists, but they certainly have something going for them in that they standardise your note-taking and help you to focus on the most important elements of the session.

How Should Therapy Notes be Written Up?

There are different options, but the one I chose to look at here is SOAP. This is an acronym, meaning that each letter stands as a reminder for something you need to cover. In short, these are:

• Subjective – subjective information is about perception: how someone experiences things in their own mind. It’s based on the client’s feelings or opinions rather than facts. The subjective part of your notes is often the longest; it includes the case history, along with how the client has been feeling since your last meeting, and how well they feel they are progressing. For example, the client may say they are feeling generally more positive.
• Objective – objective information is based on facts. It’s measurable and observable and does not take into account feelings or opinions. This section might include factual information the client gives you, or your own factual observations. For example, you might record examples of language that demonstrate their new positivity, the result of an assessment form such as GAD7, or a SUD (subjective units of distress) score.
• Assessment (and reassessment) comes next – this is your professional opinion about how well the client is doing. It might include comparing their progress with your therapy plan and noting any amendments to it, or checking their goals to ensure that things are going in the right direction.
• Planning – a look ahead. Include tasks to be completed by either you or the client between sessions. I also make a note about what techniques or scripts I have used, and why, plus any leaflets or advice I have given the client.

A Therapy Notes Example

Here’s an example of SOAP therapy notes based on a fictitious client session.

• S – Mabel reports that she is finding it easier to stick to her diet and make healthy choices about exercise. She feels proud of the progress she has made and is starting to like what she sees in the mirror. There was a setback when her husband tried to persuade her to share a bar of chocolate with him. He recognised that she was upset, but did not seem to understand why. She felt he had broken his promise to be supportive and wondered if he really understood how important it was to her to lose weight.
• O – Mabel went out for a meal with friends and chose to eat salad and fruit, when they all had heavy meals. She is looking slimmer, she has lost 14lbs since therapy began and dropped a dress size. She has a new hairstyle this week and is making more eye contact than before, suggesting increased confidence. When talking about her husband her body language changed, she slumped in the chair and appeared tearful.
• A – Mabel is progressing well for both weight loss goals, as she has reduced her portions and undertaken regular exercise. She is on track to reach her initial target of reducing by 16lb in 8 weeks.
• P – Continue with the original therapy plan, plus we agreed on another target of being more resilient when tempted to break her diet by others, especially her husband.
  Hypnotherapy in this session: Elman induction, peaceful place, control room metaphor to reinforce changes, (we turned up ‘resilience’ and ‘determination to be slim’, and turned down ‘being influenced by others’), protective bubble. All were chosen to continue improvements and increase resilience.
  Mabel is to continue to listen to my weight control audio daily. I will email her the URL of my blog containing resilience tips.

So, do you use a specific format to write up your notes? Or are you game to try this one? Let me know how it goes.

Free Download

To make the SOAP structure easier to use in practice, I’ve created a free printable SOAP therapy notes template for therapists. You can download it below and adapt it to suit your own record-keeping system or the guidance of your professional body.

References

CNHC (2024). Code of Conduct, Ethics and Performance. [online] Available at: https://www.cnhc.org.uk/uploads/asset/file/35/CodeofConductEthicsandPerformance.pdf. [Accessed 12.3.26]

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Disclaimer
The information and ideas shared on this blog are based on the author’s professional experience, research, and training. They are intended for educational purposes and to support reflection and professional development. Therapists should always apply their own professional judgment and consider the needs of individual clients when using any techniques or suggestions discussed here.
While every effort is made to ensure the information is accurate and helpful, no responsibility can be accepted for any loss, damage, or difficulties arising from the use or misuse of material contained in these articles.