Creating a custom template requires well-structured sections to ensure accurate and efficient documentation. Below are example sections you can add to your custom template, each with a description and sample content instructions.
Common Sections to Include
1. Subjective
Description: Document the client’s reported symptoms, concerns, and medical history.
Example Instruction: "Summarize the client’s presenting complaint, reported symptoms, and relevant personal history."
2. Objective
Description: Record observed behaviors, test results, and clinician observations.
Example Instruction: "Include measurable data such as vitals, observed behaviors, and physical examination findings."
3. Assessment
Description: Summarize clinical impressions, diagnosis, or differential diagnosis.
Example Instruction: "Describe the clinician’s analysis of symptoms, diagnosis considerations, and clinical interpretations."
4. Plan
Description: Outline the treatment strategy, next steps, and follow-up actions.
Example Instruction: "Detail the recommended treatment approach, medication adjustments, and follow-up schedule."
5. Interventions
Description: Record therapeutic techniques, counseling strategies, and interventions provided.
Example Instruction: "Document specific interventions used, such as CBT techniques, EMDR, or Psychoeducation."
6. Risk Assessment
Description: Assess potential risk factors, safety concerns, and protective factors.
Example Instruction: "Identify any immediate risks, protective factors, and mitigation strategies."
7. Client Progress
Description: Track client improvements, setbacks, and overall therapy progression.
Example Instruction: "Summarize the client’s progress since the last session, including response to treatment."
8. Treatment Goals
Description: Define client goals and measure progress toward achieving them.
Example Instruction: "List short-term and long-term treatment goals and any updates on their progress."
9. Session Summary
Description: Provide an overall summary of the session, including key discussion points.
Example Instruction: "Summarize the main topics discussed in the session, key takeaways, and action items."
10. Recommendations
Description: Suggest follow-up care, referrals, and next steps for the client.
Example Instruction: "Include referrals, self-care recommendations, and adjustments to the treatment plan."
11. Mental Status Examination (MSE)
Description: Document observations about the client’s mood, behavior, and cognitive function.
Example Instruction: "Describe the client’s appearance, mood, affect, thought process, and cognitive function."
12. Diagnosis
Description: Provide the diagnostic impression and any relevant DSM/ICD codes.
Example Instruction: "List the primary and secondary diagnoses with supporting clinical observations."
13. Medication Management
Description: Track prescribed medications, dosage adjustments, and client response.
Example Instruction: "Document current medications, changes in dosage, side effects, and adherence."
14. Therapeutic Approach
Description: Summarize the therapeutic techniques and interventions used in the session.
Example Instruction: "Detail the therapeutic modalities used, such as CBT, DBT, or mindfulness techniques."
15. Barriers to Treatment
Description: Identify any obstacles affecting treatment progress.
Example Instruction: "List challenges like lack of support, financial issues, or resistance to therapy."
16. Crisis Management
Description: Outline the response plan for crisis situations, if applicable.
Example Instruction: "Describe the safety plan, interventions used, and follow-up recommendations for crisis management."
17. Client Strengths & Resources
Description: Highlight the client’s strengths and external resources aiding their progress.
Example Instruction: "Document personal strengths, coping mechanisms, and community resources available."
18. Session Notes & Key Insights
Description: Summarize key discussion points, client responses, and progress markers.
Example Instruction: "Capture client reflections, therapist insights, and any significant breakthroughs."
19. Homework & Assignments
Description: Outline tasks for the client to complete before the next session.
Example Instruction: "Describe assignments such as journaling, exposure exercises, or behavioral tracking."
20. Follow-Up Plan
Description: Define the next steps and planned interventions.
Example Instruction: "Summarize upcoming goals, scheduling considerations, and next session focus areas."
Final Thoughts
Use these sections as a starting point for building customized, structured templates that suit your practice.
Combine multiple sections to create a well-rounded note format tailored to your documentation needs.
Adjust content instructions to refine how the AI generates text for each section.