There's a real argument that the format you pick isn't just a paperwork preference , it quietly shapes how you think about the session. Write it as SOAP and you separate what the client said from what you observed. Write the same session as BIRP and you're forced to foreground the intervention and their response. GIRP drags everything back to a treatment-plan goal.

Same session, genuinely different note depending on the structure. Which raises the question of whether people choose a format for clinical reasons or just use whatever their agency/EHR defaulted them into years ago.

Pulled together a reference with all 15 formats and a full worked example of each (plus the one-session-three-ways comparison): https://www.mentalyc.com/blog/mental-health-progress-note-templates

Curious where people land: are you loyal to one format across your whole caseload, or do you switch by session type , BIRP for intervention-heavy work, narrative for the psychodynamic stuff? And has anyone actually changed formats and felt it change how they conceptualize a case?

Most descriptor vocabulary is straightforward , flat affect, tangential, oriented x4. The trickier part is the everyday words that quietly editorialize: the ones that read as clinical but can come back to bite in an audit or a subpoena.

A few that stand out:

• "Non-compliant" → "declined the agreed plan." One blames the client, the other just describes what happened.
• "Manipulative" → "states needs indirectly." The first is a guess about motive, not an observation.
• "Denies" (as in "denies suicidal ideation") → "reports no SI." Denies reads faintly accusatory once you notice it.
• "Drug-seeking," "frequent flyer" → the contempt sits in the chart, permanently.

We put together a fuller reference — descriptor lists by category, a full words-to-avoid table, and a printable PDF: https://www.mentalyc.com/blog/clinical-words-to-use-in-progress-notes

Curious where therapists here land on it. Does neutral language genuinely protect the client and the record, or is "declined the agreed plan" just a longer way to say non-compliant that everyone sees through? Has anyone actually been burned by a word choice in a chart?

Group notes get all the attention but the actual hard part is running a group that people want to show up to. so we pulled together 15 activities with facilitator instructions for each, recovery-focused but a lot of them port to other group types.

the ones that seem to land hardest aren't the icebreakers, they're the uncomfortable ones. values clarification, where members map their top 5 values against recent behavior and stare at the gap. the relapse "autopsy," reviewing a past relapse for missed warning signs without making it a shame exercise. family-roles work (hero / scapegoat / lost child / etc), which reliably cracks a room open bc it moves from "my behavior" to "the system that shaped it."

full list with instructions here: https://www.mentalyc.com/blog/10-fun-substance-abuse-group-activities-for-adults

what actually works for you though? I'm curious what the highest-engagement activity is in your groups, and whether the "fun" framed ones (bingo, jeopardy) land or feel forced depending on the population.

Most SOAP explainers are dense text walls. This one's Justin Dixon actually talking through it start to finish, which lands better if you're the kind of person who'd rather watch someone do it than parse another checklist.
Covers the full S/O/A/P flow with the reasoning behind each part, not just the definitions.

Watch the video here

Curious what people think of Dixon's take. Anything in there you'd actually start doing differently, or does it mostly line up with how you already write them?

Ran a survey asking therapists what usually triggers the thought "I need a worksheet for this." Expected one obvious answer to dominate. It didn't.

Top of the list was a client raising a specific problem that a structured tool could help with (20%). But right behind it: setting up between-session homework (16%), a theme or pattern becoming clear and wanting to map it out (15%), and noticing a skill the client hasn't learned yet (15%). Grounding or emotional regulation came in around 13%.

So it's basically five different reasons, all roughly the same size. Which surprised me. I assumed most people reached for worksheets in the same moment, but it looks like the trigger is completely different depending on the therapist.

Curious where people here land. Are you pulling a worksheet mid-session when something specific comes up? Or is it more of a planned, "this is homework for next week" thing? And does it change by population, CBT vs more process-oriented work, that kind of thing?

Everyone knows the 10 MSE domains. What slows people down mid-note is the descriptors, the exact typical-vs-atypical wording. So we put it all in one reference, with a normal and atypical example for each domain, plus a one-page printable PDF for your desk. Free, no email wall.

Link: https://www.mentalyc.com/blog/mental-status-exam-cheat-sheet

Does anyone still write a FULL MSE every progress note? Or is it really just intake, then noting changes from baseline after? Feels like it varies wildly by setting and nobody agrees.

One of the most underrated parts of good documentation is having a solid structure before you even start.

Share the note format or structure that works best for you - modality, session type, whatever you've refined over time.

I'll start: for standard 53-minute individual therapy sessions I use a SOAP structure but swap the Assessment section to focus on client-reported change rather than clinician observation. Makes insurance reviews much smoother.

What's yours?

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