Building Therapy Documentation

Why therapy notes are different

Therapy documentation differs fundamentally from medical SOAP notes. Medical notes focus on physical findings, lab results, and diagnostic reasoning. Therapy notes focus on session dynamics, therapeutic interventions, client affect and behavior, treatment progress, and the therapeutic relationship. The Subjective section captures the client perspective and presenting concerns. The Objective section documents observed behavior, affect, and engagement rather than vital signs. The Assessment tracks treatment progress rather than differential diagnosis.

SOAPNoteAPI has four mental health specialties, each tuned for different documentation requirements. Choosing the right one is critical for generating notes that match your clinical workflow and insurance audit expectations.

Choosing the right specialty

psychotherapist

Standard therapy SOAP notes. Best for licensed therapists (LCSW, LMFT, LPC, PhD, PsyD) documenting individual, couples, or group sessions. Produces notes with session dynamics, therapeutic interventions used, client affect observations, and treatment progress.

{
  "transcript": "Client discussed ongoing anxiety related to work deadlines. Explored cognitive distortions around perfectionism. Used Socratic questioning to challenge all-or-nothing thinking about project outcomes. Client identified three alternative thoughts. Practiced diaphragmatic breathing exercise in session. Client reported feeling calmer after exercise. Assigned homework to practice breathing technique daily and log automatic negative thoughts.",
  "specialty": "psychotherapist"
}

psychotherapistv2

Enhanced therapy notes with questionnaire support and audit-ready formatting. Best for practices that need insurance-compliant documentation with structured progress measures, treatment plan alignment, and clear medical necessity language. Supports PHQ-9, GAD-7, and other standardized assessment scores when provided in the transcript or context.

{
  "transcript": "Session 12 of 16 authorized. PHQ-9 score today is 8, down from 14 at intake. Client reports improved sleep and fewer panic episodes this week, down to one from three last week. Continued CBT work on catastrophic thinking patterns. Reviewed thought record homework. Client successfully identified and challenged 4 of 5 automatic thoughts this week. Introduced behavioral activation scheduling for next week.",
  "specialty": "psychotherapistv2",
  "context": {
    "patient_info": {
      "name": "Sarah Chen",
      "age": 29,
      "gender": "female",
      "medical_history": "Major depressive disorder, recurrent, moderate. Generalized anxiety disorder. No prior psychiatric hospitalization."
    },
    "patient_history": "Intake PHQ-9: 14. GAD-7: 12. Treatment plan: 16 sessions CBT for depression and anxiety. Session frequency: weekly. Goals: reduce PHQ-9 below 10, develop coping skills for anxiety."
  }
}

social_worker

Social work documentation including psychosocial assessments, care coordination, resource referrals, and case management. Best for LCSWs, LMSWs, and case managers who document social determinants of health, community resource connections, and interdisciplinary coordination.

{
  "transcript": "Met with client to discuss housing instability. Client was notified of eviction last week. Reviewed emergency housing resources and provided referral to community legal aid for tenant rights. Client also reports difficulty affording medications. Connected client with patient assistance program application. Discussed safety plan given increased stress. Client denies SI/HI. Scheduled follow-up for next week to check on housing situation and medication access.",
  "specialty": "social_worker"
}

psychiatrist

Psychiatric evaluation format with Mental Status Exam, medication management, diagnostic formulation, and risk assessment. Best for psychiatrists and PMHNPs who focus on psychopharmacology, diagnostic assessments, and medication titration.

{
  "transcript": "Follow-up for medication management. Patient started sertraline 50mg two weeks ago. Reports mild nausea first 3 days, now resolved. No improvement in mood yet. Sleep still disrupted, waking at 3 AM. Denies suicidal ideation, homicidal ideation, auditory or visual hallucinations. Appetite fair. MSE: alert, oriented, cooperative. Mood described as sad. Affect constricted but reactive. Thought process linear and goal-directed. Plan to increase sertraline to 100mg, continue for 4 weeks, and reassess. Discussed expected timeline for therapeutic effect.",
  "specialty": "psychiatrist"
}

Specialty comparison

• psychotherapist -- Session dynamics, interventions, therapeutic techniques, homework, treatment progress. SOAP format.
• psychotherapistv2 -- Everything in psychotherapist plus structured assessment scores, session count tracking, treatment plan alignment, medical necessity language. Audit-optimized SOAP format.
• social_worker -- Psychosocial assessment, care coordination, resource referrals, social determinants, case management. SOAP format with social work framing.
• psychiatrist -- Mental Status Exam, medication management, diagnostic formulation, risk assessment, psychopharmacology. Medical-psychiatric SOAP format.

Handling sensitive content

Therapy sessions frequently involve sensitive disclosures: suicidal ideation, self-harm, abuse, trauma, substance use, and other high-risk topics. SOAPNoteAPI does not filter or redact clinical content -- it documents what is clinically present in the transcript, which is the correct behavior for clinical documentation.

• Suicidal ideation (SI) and homicidal ideation (HI) are documented when present in the transcript. Build your UI to flag notes containing risk language.
• Abuse disclosures are documented as reported. Your platform should prompt mandatory reporting workflows where required by jurisdiction.
• Substance use is documented clinically. No content is filtered or sanitized.
• The provider reviewing the note is responsible for clinical safety decisions. SOAPNoteAPI is a documentation tool, not a clinical decision support system.

Insurance and audit readiness

Insurance auditors reviewing therapy claims look for specific documentation elements. SOAPNoteAPI formats therapy notes to support these requirements when the right information is included in the transcript and context.

• Medical necessity -- Use psychotherapistv2 and include diagnosis and treatment plan context. The generated note will reference treatment goals and document why continued sessions are necessary.
• Session count tracking -- Include the session number and authorized session count in your transcript or context. psychotherapistv2 formats this prominently.
• Standardized measures -- Mention PHQ-9, GAD-7, PCL-5, or other scores in the transcript. psychotherapistv2 structures these in the Objective section.
• Treatment plan alignment -- Include treatment plan goals in patient_history context. The AI will document progress toward those specific goals.
• Interventions used -- Name the specific therapeutic interventions in the transcript (CBT, DBT, EMDR, motivational interviewing). The note will document these in the Objective section.

Full example: therapy session with context

const response = await fetch("https://api.soapnoteapi.com/v1/note", {
  method: "POST",
  headers: {
    "Authorization": "Bearer YOUR_API_KEY",
    "Content-Type": "application/json",
  },
  body: JSON.stringify({
    transcript: "Session 8 of 16. Client reports a difficult week with increased anxiety after a conflict with supervisor. PHQ-9 today is 10, GAD-7 is 11. Explored the workplace conflict using CBT framework. Identified catastrophic thinking pattern: believes she will be fired. Challenged evidence for and against this belief. Client able to generate balanced thought that one conflict does not determine employment outcome. Practiced progressive muscle relaxation. Assigned homework: daily thought records focusing on workplace triggers, continue breathing exercises.",
    specialty: "psychotherapistv2",
    context: {
      patient_info: {
        name: "Sarah Chen",
        age: 29,
        gender: "female",
        medical_history: "MDD recurrent moderate, GAD. No prior hospitalizations.",
      },
      patient_history: "Intake 2026-01-15. PHQ-9 at intake: 14, GAD-7 at intake: 15. Treatment plan: 16 sessions weekly CBT. Goals: (1) reduce PHQ-9 below 10, (2) develop 3+ coping skills for anxiety, (3) improve workplace functioning. Session 7: PHQ-9 12, GAD-7 13. Client learning thought challenging but struggles to apply in the moment.",
      custom_instructions: "Include session number and authorized total. Reference treatment plan goals in assessment. Note progress on each goal.",
    },
    include_billing_codes: true,
  }),
});

const note = await response.json();
console.log(note);

Python equivalent

import requests

response = requests.post(
    "https://api.soapnoteapi.com/v1/note",
    headers={
        "Authorization": "Bearer YOUR_API_KEY",
        "Content-Type": "application/json",
    },
    json={
        "transcript": "Session 8 of 16. Client reports a difficult week with increased anxiety after a conflict with supervisor. PHQ-9 today is 10, GAD-7 is 11. Explored the workplace conflict using CBT framework. Identified catastrophic thinking. Client generated balanced thought. Practiced progressive muscle relaxation.",
        "specialty": "psychotherapistv2",
        "context": {
            "patient_info": {
                "name": "Sarah Chen",
                "age": 29,
                "gender": "female",
                "medical_history": "MDD recurrent moderate, GAD.",
            },
            "patient_history": "Intake PHQ-9: 14, GAD-7: 15. 16 sessions CBT authorized.",
            "custom_instructions": "Include session count and treatment plan goal progress.",
        },
        "include_billing_codes": True,
    },
)

note = response.json()
print(note)

Best practices for therapy platforms

• Default to psychotherapist for general therapy. Upgrade to psychotherapistv2 when insurance documentation or audit readiness is a priority.
• Use psychiatrist only for medication management and psychiatric evaluation visits, not talk therapy sessions.
• Pre-populate context from your EHR. Pass diagnosis, treatment plan goals, and prior session scores automatically so the provider does not have to re-enter them.
• Build a review step. Therapy notes require careful review because sensitive content and therapeutic nuance must be accurate. Never auto-file therapy notes without provider approval.
• Consider session type. Group therapy, couples sessions, and family sessions may need custom_instructions to clarify the documentation format expected.