Most therapists already know how to write good notes. The question is: how do you maintain that quality while protecting your capacity for clinical work?
Documentation strategies that support sustainable practice:
- Using consistent note templates (like SOAP or DAP) reduces cognitive load
- Session prep and real-time notation capture details without relying on end-of-day recall
- Batched documentation time minimizes context switching
- Phrase libraries maintain consistency across your practice
- AI documentation tools generate drafts based on your clinical input
The goal isn’t just speed, it’s clarity, structure, and protecting your mental energy for the clinical work itself. Your notes continue to reflect your clinical judgment, supported by systems designed to work the way you actually practice.
Why It Matters to Write Progress Notes Efficiently
You already understand why documentation matters: continuity of care, clinical accountability, regulatory compliance. The challenge isn’t knowing why to document. It’s finding sustainable systems that let you document well without exhausting your capacity for the work itself.
They also protect you. If you ever need to reference past decisions, explain your clinical reasoning, or respond to an audit, your notes have your back.
The problem? They take time. And when you’re seeing back-to-back clients, that time adds up.
Writing better progress notes isn’t about rushing through them. It’s about getting smarter with how, when, and where you document. With a few simple strategies and tools designed to support your clinical work, you can take notes that are fast, focused, and reliable.
Which Therapy Note Format Should You Use?
You likely already have a preferred documentation format. Smart Notes supports the structures you’re already using: SOAP, DAP, or custom templates that match your clinical approach and both are supported by many digital tools and AI platforms.
What Is a SOAP Note?
SOAP stands for:
- Subjective: What the client says (e.g. “I’ve been really anxious lately”)
- Objective: What you observe (e.g. client was fidgeting and avoided eye contact)
- Assessment: Your interpretation (e.g. anxiety is increasing due to work stress)
- Plan: What you’ll do next (e.g. continue CBT, introduce exposure exercise)
The SOAP Note format is especially useful when you need structure and clarity. It’s widely used in both mental health and medical settings.
Example of a SOAP note:
S: Client reports avoiding work events due to anxiety.
O: Tense posture, spoke rapidly.
A: Social avoidance linked to core beliefs around self-worth.
P: Use cognitive restructuring. Assign social exposure for homework.
★ Master SOAP Notes & download a free template here!
What Is a DAP Note?
DAP is a simpler, more flexible format:
- Data: What the client said and what you observed
- Assessment: Your clinical interpretation
- Plan: Your treatment goals or next steps
Mental health professionals often prefer DAP notes because they’re concise and straight to the point.
DAP notes work especially well for therapists who see multiple clients back-to-back and need a fast way to document each session without missing key information.
Quick Takeaway: Choose the note format that works for your style. SOAP offers a bit more structure. DAP is great for speed and simplicity. Either one can be enhanced with AI tools, custom templates, and note libraries.
Documentation Strategies That Protect Your Capacity
You may already use some of these approaches. They’re worth reviewing because small optimizations compound over time.
1. Consistent Structure
Using the same documentation format reduces cognitive load. When your structure is consistent, you can focus on clinical content rather than deciding how to organize each note.
Consistent formatting also makes your notes easier to review later, particularly important when working in teams or managing transitions of care.
2. Session Prep and Real-Time Notation
Capture basic information before the session starts: date, session number, presenting concern. Review the previous note and set session intentions.
Brief in-session notation, when clinically appropriate, reduces reliance on memory. You don’t need detailed documentation during the session, just enough to support accurate post-session notes.
3. Batched Documentation Time
Writing notes sporadically between clients can fragment your focus.
Many practitioners find batching more sustainable: block 30 to 60 minutes once or twice daily to complete all notes. This approach reduces context switching and maintains documentation momentum.
4. Build Your Phrase Library
Most practitioners use similar language across clients. A curated phrase library saves time while maintaining consistency.
Examples: “Client engaged in cognitive reframing” “Used grounding techniques to manage dissociation” “Processing continued regarding childhood trauma”
Digital documentation tools often support drop-down menus or macros for commonly used clinical language.
Quick Takeaway: Sustainable documentation comes from systems that match how you work. Consistent templates, strategic prep, scheduled writing time, and phrase libraries protect your capacity without compromising quality.
How AI Documentation Works for Regulated Professionals
AI tools generate drafts based on your clinical input. You maintain full editorial control: reviewing, refining, and finalizing every note before it becomes part of the record.
How It Works
- You provide a session summary, bullet points, an audio/video file or use integrated telehealth platform
- The AI tool creates a draft in your chosen format (SOAP or DAP)
- You make edits and save the final version to your record
This can cut your documentation time in half, or more, while still allowing you to write notes in your own voice.
Benefits of Using AI for Notes
- It saves time. No more starting from scratch
- It increases consistency. Standard language and structure help reduce mistakes
- It improves clarity. Well-organised notes make reviews and audits easier
- You stay in control. You decide what to keep, change, or delete
What About Privacy?
If you’re in Canada, privacy laws matter. A good AI tool should be PHIPA and PIPEDA-compliant. That means it protects client information with secure storage, encryption, and therapist-controlled access.
Smart Notes, for example, was built specifically for Canadian therapists and meets all of these standards.
Quick Takeaway: AI tools like Smart Notes don’t replace you. They help you get started faster, stay consistent, and reduce the paperwork load. You’re still the therapist. The tool just supports your process.
Smart Notes: AI Documentation Built for Canadian Practitioners
Designed alongside regulated professionals to meet the operational standards you expect. Compatible with your existing workflow, customizable to your clinical approach, compliant with PIPEDA and provincial College requirements.
With Smart Notes, practitioners can save up to 8 hours per week on documentation (based on 20 sessions per week, 25 minutes saved per note). Document at the end of the day without losing important details, particularly valuable when managing back-to-back sessions. Review, refine, and keep only what serves your clinical needs.
Why Practitioners Choose Smart Notes
- Generates drafts in SOAP, DAP, or rich text format
- Integrates with your existing workflow
- Maintains secure, therapist-controlled data
- Built-in informed client consent forms through Client Portal
- Compatible with both teletherapy via Scribe Session and in-person sessions via uploaded media file
- Prefer AI-free sessions? Dictate a summary afterward and upload — Smart Notes does the rest.
Quick Takeaway: Smart Notes functions as documentation support that drafts your notes based on your clinical input. You maintain full control while working more efficiently.
Final Thoughts: Documentation Systems That Support Your Practice
Clinical documentation is essential to quality care. The question is whether your current systems support or drain your capacity.
With consistent templates, strategic routines, and tools like Smart Notes, you can maintain professional, thorough documentation while protecting time for clinical work.
Consider evaluating one aspect of your documentation workflow this week. Maybe it’s scheduling dedicated documentation time. Or exploring whether an AI tool could support your current process.
Documentation systems should support your clinical judgment, not drain your capacity for it.
Want to see how Smart Notes works? Explore the tool here.
FAQs: Progress Notes, Formats, and AI Tools for Therapists
What are progress notes in therapy?
They’re short clinical records written after each session. Progress notes track the client’s status, interventions used, and treatment plans. They’re required for both legal and ethical reasons.
How can I write therapy notes faster?
Use a structured format like SOAP or DAP. Take quick notes during sessions, and batch your documentation time. Consider using an AI progress notes tool to help draft notes.
What are SOAP notes?
SOAP notes are a structured format for documenting sessions. They include four sections: Subjective, Objective, Assessment, and Plan.
What’s a DAP note?
DAP stands for Data, Assessment, and Plan. It’s a simpler format often used by mental health professionals for its clarity and speed.
Can AI help me write progress notes?
Yes. AI clinical documentation tools like Smart Notes can generate drafts based on your session input. You edit the draft before saving it.
Is AI documentation secure?
If the tool is PHIPA and PIPEDA-compliant (like Owl Practice’s Smart Notes), it should offer encrypted storage, therapist access controls, and privacy features that meet provincial standards.
Can AI create SOAP or DAP notes?
Absolutely. Most AI tools are designed to format your notes as SOAP or DAP drafts, depending on your preference. You review and finalise them before saving.
Coming Soon: Owl Practice will be launching an AI Note Taker tool!
Learn more about Owl Practice’s upcoming feature, Smart Notes, here!
Reduce clinical administrative tasks and transform more lives with Owl Practice. Owl Practice provides all the tools you need to make your practice successful. Join the thousands of care professionals using Owl to run their practice every day.
