Features
Clinical Note Templates for Psychology Practices
Progress note templates for outpatient psychologists and psychiatrists — session structure, outcome measures, signing, and psychiatry documentation.
Updated June 12, 2026 · 6 min read
Progress notes are the legal and clinical record of each therapy session. Templates shaped for outpatient psychology — not hospital nursing flowsheets — save time and improve consistency across clinicians in a group practice.
What psychology note templates should include
- Session date, duration, modality (in-person / telehealth), participants
- Presenting concerns and interval history since last visit
- Mental status or clinical observations relevant to your modality
- Interventions used and client response
- Risk assessment documentation when clinically indicated
- Plan — homework, next appointment, referrals
- Outcome measure scores when administered (PHQ-9, GAD-7, etc.)
Outcome measures in the note
When PHQ-9 or GAD-7 is completed, the note should reflect scores and change from prior administrations without retyping. Integrated software pulls latest measures into the documentation workflow.
Psychology vs psychiatry documentation
Psychology / therapy
Emphasis on psychotherapy process, goals, and behavioral observations.
Outpatient psychiatry
May add medication review, med-management sections, and psychiatry-specific outcome panels (e.g. MADRS, YMRS where used) — still outpatient, not inpatient ward rounds.
Signing, cosign, and amendments
- Clear author and sign timestamp on each note
- Supervisor cosign workflow for trainees per policy
- Amendments addended — not silent overwrites of signed content
- Link between signed note and billable visit for compliance
FAQ
- Should psychology notes use hospital EMR templates?
- No — outpatient therapy notes need session-focused progress documentation, not inpatient nursing or admission formats.
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