Accurate and detailed clinical documentation is crucial for psychologists in providing high-quality patient care. Psychology session notes, often structured in a SOAP (Subjective, Objective, Assessment, Plan) format, ensure that patient interactions are recorded systematically. This guide will walk you through correctly writing and formatting these notes, using an example template and highlighting how AI medical scribes like Notis can streamline this process.

Writing and Formatting Psychology Session Notes

Out of Session Task Review

Begin by reviewing tasks assigned to the client outside the session. For instance, "Client practiced mindfulness techniques daily as discussed in the last session. Client reported that the mindfulness exercises helped reduce anxiety levels. Client faced difficulty in maintaining focus during the exercises due to intrusive thoughts."

Current Presentation

Document the client's current psychological state and symptoms. Example: "Client reported increased anxiety and difficulty sleeping. Client mentioned feeling more irritable and having frequent mood swings."

Session Content

This section should detail the main topics covered in the session, including any therapeutic interventions and discussions. For example: "Client discussed ongoing stress at work and its impact on mental health. Explored coping strategies for managing work-related stress. Discussed therapy goals of reducing anxiety and improving sleep quality."

Intervention

Describe the interventions used during the session and the client's response. An example entry might be: "Utilised Cognitive Behavioural Therapy (CBT) techniques to address negative thought patterns. Introduced deep breathing exercises to help manage anxiety."

Setbacks/Barriers/Progress with Treatment

Note any challenges the client faces with treatment, as well as progress made. For instance: "Client reported difficulty in applying CBT techniques consistently. Client expressed satisfaction with the progress made in managing anxiety."

Risk Assessment and Management

Assess and record any potential risks, including suicidal ideation, self-harm, or aggression. Example: "Suicidal Ideation: Client denied any history of suicidal ideation or attempts. Management Plan: Continue with CBT and mindfulness exercises to manage anxiety and stress."

Mental Status Examination

Conduct and document a mental status examination, including observations on appearance, behavior, mood, and cognition. For example: "Appearance: Client appeared well-groomed and appropriately dressed. Mood: Client described feeling anxious and stressed."

Out of Session Tasks

Assign tasks to the client to continue progress outside sessions. Example: "Client to continue practicing mindfulness exercises daily and keep a journal of thoughts and feelings."

Plan for Next Session

Outline plans for the upcoming session, including date and focus areas. Example: "Next Session: Scheduled for 15/09/2024 at 2:00 PM. Plan to address further stress management techniques and review progress with mindfulness practice."

Automating Documentation with AI Medical Scribes

While manual documentation is essential, it can be time-consuming. AI medical scribes like Notis offer an efficient solution, particularly for psychology professionals. Notis automates the transcription of patient interactions into structured SOAP notes, drastically reducing the time spent on documentation.

Key Benefits of Notis for Psychologists

Time Efficiency: Notis can cut down documentation time by 80%, freeing up psychologists to focus more on patient care. On average, users save up to 2 hours per day on administrative work.

Ease of Use: Operating through WhatsApp, Notis eliminates the need for additional software, providing a seamless transition for users.

High Accuracy: With voice-to-text technology boasting 99% accuracy, Notis ensures precise documentation of medical notes, supporting the psychologist's workflow.

Comprehensive Documentation: Notis converts consultations into structured SOAP notes instantly, and its smart search feature allows easy retrieval of patient information.

By integrating AI medical scribes like Notis, psychologists can enhance the accuracy and efficiency of their patient documentation, ultimately improving the quality of care provided.