Generate therapy session progress notes
AI asks about session goals and content, then writes a complete progress note ready for the medical record.
Generate therapy session progress notes
River's Therapy Progress Note Generator creates professional, comprehensive progress notes for counseling and therapy sessions. You provide session content, interventions used, client progress toward goals, and plan for next session, and the AI writes a complete progress note in proper clinical format. The note documents therapeutic work, tracks goal progress, maintains continuity of care, and meets documentation requirements. Perfect for therapists, counselors, social workers, and psychologists managing clinical caseloads.
Unlike rushing through notes between sessions, this AI structures session information into properly formatted progress notes. The tool captures presenting concerns, interventions delivered, client response, progress toward treatment goals, and next session plan. The note provides clear documentation of clinical work while respecting therapeutic relationship. You focus on client care during sessions, then efficiently document therapeutic process.
This tool is perfect for licensed therapists managing full caseloads, counselors documenting individual or group sessions, social workers providing psychotherapy, or psychology trainees learning documentation. If progress notes take too long after sessions or documentation feels burdensome, this creates professional therapeutic documentation efficiently. Use it for any counseling or therapy session requiring clinical progress note.
What Therapy Documentation Must Include
Effective therapy progress notes document the clinical work while protecting client privacy and therapeutic relationship. They must demonstrate medical necessity, show progress toward treatment goals, document interventions used, and support continued treatment. Weak notes are vague (we discussed feelings), lack connection to treatment goals, or contain excessive personal details that don't serve clinical purpose. Strong notes focus on clinically relevant information: symptoms addressed, interventions applied, progress made, and plan forward. The note should demonstrate therapeutic work occurred and treatment remains necessary.
Complete therapy progress notes typically include: presenting concerns for this session, interventions and techniques used, client response and engagement, progress toward treatment goals with specific observable changes, risk assessment when indicated, clinical impression or symptoms observed, and plan for next session. Many therapists use structured formats like DAP (Data, Assessment, Plan) or BIRP (Behavior, Intervention, Response, Plan). Whatever format you use, document should support medical necessity, track progress, and provide continuity if another provider needs to understand treatment course.
Therapy notes have special legal and ethical considerations. Distinguish between progress notes (part of medical record, accessible to client and payers) and process notes (therapist's private notes about session process). Progress notes should contain only information necessary for treatment continuity and billing, not detailed personal disclosures that might damage therapeutic relationship if released. Include enough to demonstrate clinical work and progress, but respect client privacy. Notes protect you professionally by documenting appropriate care while maintaining ethical boundaries around confidential therapeutic content.
What You Get
Complete therapy progress note with all required sections
Session content and interventions documented
Progress toward treatment goals tracked
Client response and engagement noted
Risk assessment when indicated
Plan for next session and ongoing treatment
How It Works
- 1Provide session detailsAI asks about presenting concerns, interventions, client progress, and plan
- 2AI writes noteGenerates complete progress note in 5 minutes
- 3Review and finalizeEnsure accuracy, maintain appropriate boundaries, verify completeness
- 4Add to recordComplete in EHR or practice management system
Frequently Asked Questions
What's the difference between progress notes and process notes?
Progress notes are official medical records documenting clinical work, goals, and medical necessity. They're accessible to clients and insurance companies. Process notes are therapist's private reflections about session dynamics and treatment approach, protected under psychotherapy notes rules. This tool creates progress notes for the medical record. Keep detailed personal disclosures or transference observations in separate process notes not part of official record.
How much detail should I include about session content?
Include enough to demonstrate clinical work and progress without excessive personal detail. Document themes addressed (anxiety about relationships, coping with grief, anger management skills), interventions used (cognitive restructuring, exposure therapy, mindfulness practice), and client response (engaged with homework, resisted exploring topic, showed insight). Don't include verbatim sensitive disclosures unless clinically necessary. Focus on clinically relevant information that demonstrates therapeutic work and supports continued treatment.
How do I document risk assessment?
Include risk assessment when clinically indicated (client mentions suicidal thoughts, describes dangerous behavior, reports abuse). Document what client reported, your clinical assessment of risk level, safety planning done, and any actions taken (contacted emergency contact, coordinated higher level of care). For routine low-risk sessions, brief statement (client denies suicidal or homicidal ideation) suffices. Thorough risk documentation protects both client safety and your professional liability.
Should I document if client misses sessions or doesn't complete homework?
Yes. Document attendance patterns (client missed previous session without notice, this is first session after 2-week break). Note homework completion and engagement (client completed thought records, reported practicing skills, did not complete assigned reading). This shows treatment engagement level and helps demonstrate medical necessity. If client frequently misses or doesn't engage, document discussions about commitment to treatment and any barriers addressed.
What if I'm using specific therapy modalities like CBT or DBT?
Name the modality and specific techniques used. Instead of 'we discussed thoughts,' write 'used cognitive restructuring to identify and challenge automatic negative thoughts about social situations.' Specific intervention language demonstrates you're providing evidence-based treatment and helps justify medical necessity. Different modalities have common documentation approaches, incorporate those elements while ensuring note meets basic progress note requirements.
What is River?
River is an AI-powered document editor that helps you write better, faster. With intelligent writing assistance, real-time collaboration, and powerful AI tools, River transforms how professionals create content.
AI-Powered Writing
Get intelligent suggestions and assistance as you write.
Professional Tools
Access specialized tools for any writing task.
Privacy-First
Your documents stay private and secure.
Ready to try Generate therapy session progress notes?
Start using this tool in 60 seconds. No credit card required.
Create Progress Note →