Effective documentation is crucial - but it shouldn't eat up your valuable time. mdhub was specifically built for mental and behavioral health practitioners to simplify documentation so you can focus on what really matters. Trusted by thousands of therapists, mdhub leverages AI to automate notes, allowing you to focus more on client care and less on paperwork.
Find Your Perfect Therapy Note Template
When to Use Which Therapy Note
Choosing the right therapy note template can be tricky and depends on your specific needs, treatment settings, and documentation requirements. Understanding when to apply each template type can streamline your documentation and practice. mdhub's Clinical AI Assistant allows you to fully customize your notes and also has a selection of pre-built templates to get you started. Some of the favorite notes of therapists using mdhub are:
- Intake Notes: For initial assessments of new clients.
- Progress Notes: Regular session documentation.
- BIRP and SOAP Notes: Structured frameworks used widely for clarity and consistency.
Common Therapy Note Templates
To get you started, let's explore some essential therapy note templates you’ll frequently use in your practice and their ideal scenarios:
1. Intake Note
Therapy intake notes are designed specifically for initial client assessments, providing a comprehensive overview.
mdhub's pre-built therapy intake note has the following sections:
- Chief Complaint and History
- Symptoms and Functional Impairments
- Psychiatric and Trauma History
- Family, Social, Educational, and Employment History
- Substance Use and Medical History
- Risk Assessment
- Treatment Goals
🌐 Review mdhub's Therapy Intake Note
2. Progress Note
Therapy progress notes are great for ongoing therapy sessions to efficiently document clinical progress. While intake notes typically collect a comprehensive overview of a client's background and presenting concerns at the beginning of care, progress notes focus on tracking the client’s ongoing improvements and challenges across sessions.
mdhub's pre-built therapy progress note has the following sections:
- Chief Complaint
- Symptoms and Functional Impairments
- Session Focus
- Treatment Approaches and Interventions
- Client Response
- Homework and Plan
- Progress towards Goals
🌐 Review mdhub's Therapy Progress Note
3. BIRP Note
BIRP Notes (Behavior, Intervention, Response, Plan) are ideal for capturing session dynamics clearly, particularly useful in behavioral therapies or psychiatry where closely tracking interventions and client responses is critical. Unlike general progress notes, which broadly summarize a session, or SOAP notes, which organize information in a medical-style framework, BIRP notes focus specifically on observable behaviors, the therapist's interventions, the client's responses, and a clear plan for treatment. This structure supports more action-oriented, behaviorally focused clinical work and provides strong documentation for treatment justification.
mdhub's pre-built BIRP note has the following sections:
- Presenting Problem
- Mental Status Exam
- Risk Assessment
- Signs and Symptoms
- Behavior Observations
- Functional Impairments
- Treatment Approaches and Clinical Interventions
- Client Response
- Plan and Homework
- Medication Compliance
4. SOAP Note
SOAP Notes (Subjective, Objective, Assessment, Plan) are perfect for general session documentation, easy to use, and widely accepted by regulatory bodies. SOAP Notes organize information into four key areas - Subjective, Objective, Assessment, and Plan - making it easy to create clear, concise, and clinically relevant notes.
mdhub's pre-built SOAP note has the following sections:
- Subjective: Client's perspective or report
- Objective: Therapist's observations
- Assessment: Clinical interpretation and progress
- Plan: Next steps in treatment
Challenges with Traditional Note-Taking
Now that you got an overview of some of the common therapy templates, there is the question of how to best take your notes. Nearly all therapists, have to spend time after the session writing notes, leading to a never ending cycle of having to catch up on notes and trying to remember what happened in previous sessions. This is why we developed mdhub.
mdhub automates the documentation burden through our Clinical AI Assistant, ensuring that you're always on top of your documentation, have all of the relevant information and never have to worry about about taking notes during a session.
Simplify Your Practice with AI-Powered Therapy Note Templates
Benefits of Using mdhub for Therapy Notes
Therapists who use mdhub see immediate improvements:
- Saving an average of 2 hours daily on documentation
- Improved accuracy and uniformity across therapy notes
- Increased ability to focus on clients rather than paperwork
- Better clinical insights and continuity of care
Getting Started with mdhub
Get started and join thousands of therapists who use mdhub to streamline their documentation. Try mdhub for free today and start automating your documentation.
3 easy steps to get started with mdhub:
- Sign up at mdhub.ai
- Choose and personalize your preferred therapy note templates
- Record a session with mdhub and get the notes within seconds
