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What belongs in a session note, and what does not

Session notes are the operational record of clinical care. They are also the thing therapists most often defer to the weekend. Here is a working definition of what to include — and what to leave out.

Every clinician we have spoken to has, at some point, written a 600-word session note that no-one will ever read again, and then beaten themselves up for not writing it sooner. Long notes feel diligent. They are usually a sign that the note is being asked to do too many jobs at once.

A session note has three jobs

  • Document what happened in the session — enough that a colleague picking up the case knows where things sit.
  • Provide a defensible record if the session is ever scrutinised by a regulator, a parent, or a colleague's clinical supervisor.
  • Capture decisions made — adjustments to the plan, things to come back to next session.

What to include

Date, time, attendees, and setting. The goal worked on (referenced from the client record, not re-described). What you did, in plain language. The client's response to it — concrete, not editorialised. Any change in plan and the reason. Any safeguarding concerns, however small.

What to leave out

Background you already wrote on the client record. Long verbatim quotes from the client unless they materially change the plan. Editorialised emotional content ("I felt the family was disengaged") — replace with observable behaviour ("the family arrived 20 min late and ended the session early").

Aim for ten minutes

If a session note takes you more than ten minutes, the structure is fighting you. Either you are re-recording context that should live on the client record, or the goals are vague and you are filling the gap with prose. Both are fixable upstream.

How Carelyt fits in

Carelyt separates the client record (goals, contact, history) from the session record (what happened today). When goals live on the client, your note can reference 'goal 2' instead of restating it. The mental cost of the note drops; the safeguarding integrity stays intact.

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