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Monday, 23 January 2017

How to write up your client notes


Having never thought very much about this topic in a formal way before, I have been asked for advice on it several times recently. Whether this is serendipity, fate or just plain old coincidence I thought it would make the subject of a good blog.

The CNHC say your client record as a whole should include:
  • personal data and record of consent (tips on this part HERE
  • any correspondence with or about the client
  • your case history (tips on this part HERE)
  • your initial therapy plan and any amendments made as you go along
  • re-assessment of the client's needs
  • the care provided
  • any advice given, either verbally or by way of leaflets etc

Your session notes should cover most of this from assessment down, and it may surprise you to know that there are formal guidelines for recording these if you choose to use them. These are, I think, more familiar to counsellors than hypnotherapists, but they certainly have something going for them in that they standardise your notes taking and allow you to focus on the most important elements of the session.

There are a number of these guidelines but the one I have chosen to look at here is called SOAP. This is an acronym, meaning that each letter stands as a reminder for something you need to cover. In short, these are:

  • Subjective - subjective information is about perception: how someone experiences things in their own mind, it's based on feelings or opinions rather than facts. The subjective part of your notes is often the longest, it includes the case history, along with how the client has been feeling this since your last meeting, how well they feel they are progressing. For example, the client may say they are feeling generally more positive.
  • Objective - objective information is based on facts: it's measurable and observable and does not take account of feelings or opinions. This section might include factual information the client gives you, or your own factual observations. For example, you might record examples of language that demonstrate their new positivity.
  • Assessment (and reassessment) comes next - this is your professional opinion about how well the client is doing, comparing their progress with your therapy plan and noting any amendments to it, checking their goals to check that things are going in the right direction.
  • Planning is the final stage - a look ahead including any actions to be taken by either you or the client to move things forward. I’d include a note about what techniques or scripts you have used, and why, plus any leaflets or advice you have given the client in this part.

Here’s an example of SOAP notes based on a fictitious client.

  • S - Mabel reports that she is finding it easier to stick to her diet and make healthy choices about exercise. She feels proud of herself for the progress she's made, and is starting to like what she sees in the mirror. There was a setback when her husband tried to persuade her to share a bar of chocolate with him. She got very upset and he didn’t seem to understand why. She felt he had broken his promise to be supportive and wonders if he really understands how important it is to her to lose weight.
  • O - Mabel went out for a meal with friends and chose to eat salad and fruit, when they all had heavy meals. She is looking slimmer, she has lost 14lbs since therapy began and dropped a dress size. She has a new hairstyle this week and increased confidence is indicated by her making more eye contact than previously. When talking about her husband her body language changed, she slumped in the chair and appeared tearful.
  • A - Mabel is progressing well for both weight loss goals, as she has reduced her portions and undertaken regular exercise.
  • P - Continue with the original therapy plan, plus we agreed on another target of being more resilient when tempted to break her diet by others, especially her husband.
    Hypnotherapy in this session: Elman induction, peaceful place, control room metaphor to reinforce changes, (we turned up 'resilience' and 'determination to be slim', and turned down 'being influenced by others'), protective bubble. All were chosen to continue improvements and increase resilience.
    Mabel is to continue to listen to my weight control CD daily, I will email her the URL of my blog containing resilience tips.

It would be easy enough to have a form in your records which recorded each session in the same format and using this type of outline helps to keep your sessions focussed and on track.

So, do you use a specific format to write up your notes? Or are you game to try this one? Let me know how it goes.


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Author: is an experienced hypnotherapist and hypnotherapy trainer. She is the author of Their Worlds, Your Words and has co-written the Hypnotherapy Handbook, both of which are available from Amazon. Find out more about Debbie's services on
Yorkshire Hypnotherapy Training - multi accredited hypnotherapy practitioner training, taster days and foundation levels.
CPD Expert - accredited CPD courses (online and workshops options), expert supervision

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  6. Please would you advise me as to the GDPR for note taking. I am currently studying Hypnotherapy and I am working through the portfolio of information and cannot find the exact GDPR for notes! With thanks

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    Replies
    1. Hi, thanks for your comment. I do think this is something you should talk to your tutor about, as the school you're studying with may have specific ways of working they'd like you to use. If not, I am not a GDPR expert, but as far as I am aware the GDPR isn't about how you write up your notes, only in how you store them once they are created. And the same rules apply to that as to any other sensitive data. If they are on paper they must be in a secure, locked container. If they are in electronic form they must be password protected and you must have reasonable security in place to prevent hacking. And you must let clients have a copy if they ask for them. Hope this helps.

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