Lesson 2

Session 2: Session Notes Mastery

Topic: Writing Effective, Compliant Session Notes

• Key Concepts:

  • Core components of a session note: objective data, client responses, intervention adjustments.

  • Avoiding subjective language (e.g., “Client was happy” vs. “Client smiled and clapped 5x”).

  • Aligning notes with treatment plan goals for billing compliance.

• Activities:

  • Role-Play: Draft notes for a mock session, then peer-review for clarity and compliance.

  • Quiz: Identify compliant vs. non-compliant documentation snippets.

• Materials:

  • The Essential First Step templates (e.g., “Session Note Checklist”).

  • Video demo: “Turning Observations into Objective Data.”