Writing notes that are too vague
- “Client discussed anxiety and processed feelings.”
- The note doesn't demonstrate what actually happened in session or why the intervention was clinically appropriate.
Writing too much
- Including unnecessary personal details, extensive client history, or information that doesn't support the clinical purpose of the note.
- More documentation isn't necessarily better documentation.
Not connecting interventions to the treatment plan
- Documenting what the therapist did without explaining why it was clinically indicated.
- Example: “Used CBT techniques” → better: “Used cognitive restructuring to identify and challenge catastrophic interpretations contributing to increased anxiety.”
Failing to document medical necessity
- Notes may describe the client's symptoms but fail to establish why ongoing treatment is necessary.
Using subjective or judgmental language
- Words such as “manipulative,” “lazy,” “difficult,” “attention-seeking,” or “noncompliant” can create significant problems.
- Documentation should describe observable behavior and clinical formulation, rather than character judgments.
Poor documentation of risk
- Not documenting suicide/self-harm/homicide risk assessments when clinically indicated.
- Or documenting only “denies SI/HI” without enough context when there are other risk factors present.
Not documenting changes in risk
- A client's risk level can change over time, and documentation should reflect changes, protective factors, interventions, and follow-up planning.
Confusing what the client said with the therapist's clinical interpretation
- Good documentation distinguishes between:
- Client report
- Clinical observation
- Assessment
- Clinical formulation
Over-documenting sensitive information
- Especially trauma histories, abuse allegations, family conflict, sexual information, or forensic/legal matters.
- Therapists sometimes document details that aren't necessary to support treatment.
Using copy-and-paste language
- Repeating essentially the same note every session can make documentation appear inaccurate or disconnected from the client's actual clinical presentation.
Failing to document progress—or lack of progress
- “Continue treatment” isn't enough.
- Notes should show whether symptoms are improving, worsening, remaining stable, or changing in presentation.
Not documenting treatment-plan changes
- If goals, symptoms, interventions, frequency, or level of care change, the documentation should reflect that evolution.
Poor documentation of collateral contacts
- Therapists often forget to clearly document:
- Who was contacted
- Why
- What information was discussed
- What clinical decision resulted
Documentation that doesn't support the billing code
- The clinical picture, service provided, duration, and complexity should make sense in relation to the billed service.
Writing notes defensively instead of clinically
- Therapists sometimes become so concerned about audits, lawsuits, or subpoenas that notes become extremely rigid or unnatural.
- The goal should be objective, clinically meaningful, and defensible documentation—not documentation written solely for litigation.