Mental health session note
A two-page note for each therapy, assessment or medication review session, with a confidentiality line at the top. Headings guide what to record; the words are yours.
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- Word · English.docx · 38 KB
- PDF · English.pdf · 228 KB
- Word · Arabic.docx · 39 KB
- PDF · Arabic.pdf · 74 KB
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What is in the file
| Confidentiality line | A marked box at the top: who may read the note and that it is not shared without the patient’s permission except where the law requires it. |
|---|---|
| Session | Patient block, session number, duration, who was present, session type (assessment, therapy, follow-up, medication review) and format (in person, video, phone). |
| Mental state | Presenting issues, then free-text headings: appearance and behaviour, speech, mood, affect, thought, perception, cognition, insight and judgement. |
| Risk screen | Yes, no or not assessed for suicidal thoughts, self-harm, risk to others, safeguarding, substance use and self-neglect, each with a note, and a line for a safety plan. |
| Scales, medication, plan | Score boxes for PHQ-9, GAD-7 and two more, with no scoring guidance; medication changes with reason and prescriber; interventions, plan, liaison and the next session. |
How to use it
Add your letterhead
Open the Word file and put your logo and clinic details in the header box.
Fill it during or right after the session
Write in the patient’s words where it matters, such as mood.
Mark every risk line
Not assessed is an answer too: it shows the question was considered.
Keep it apart
File it where only the treating clinician and those they authorise can reach it.
Who it is for
Psychiatrists, psychologists and counsellors in private clinics and multi-specialty centres. The scales are blank boxes; use the instruments and cut-offs your service has adopted.
Questions
Why is there no scoring guidance?
Scales and cut-offs differ between services and change over time. The note records the score; interpretation stays with the clinician.
Can I add my own scales?
Yes. Two rows are blank, and the Word file lets you add more or rename them.
What does “not assessed” mean in the risk screen?
That the question was not asked in this session. Writing it down is clearer than leaving the line empty.
Who should see this note?
Only the treating clinician and those they authorise. In a shared clinic, store paper notes separately from the general file.
Notes only the right people can open
In Medicolize session notes live on the patient file, and role-based access decides who on your team can open them. Thirty minutes on your own clinic.