The Love-Hate Relationship with Progress Notes

Let’s be honest: progress notes are the broccoli of the therapy world. Good for you, required by insurance, and likely to make your soul wilt if you let them pile up past Friday. We’ve all had those weeks where the actual therapy part of the job is energizing—and then we open our EHR and it’s like, “Ah yes, 12 unsigned notes and a looming audit. My reward for being emotionally available.”

Enter: Artificial Intelligence 🤖. The tech world’s answer to everything, including the question we didn’t quite know we were asking: “What if someone could just write these damn notes for me?” And while we’re not quite at full-on robot therapist territory (thankfully), AI has started to show up as a very real, very powerful support tool in our workflow.

But here’s the catch: just because AI can generate a progress note doesn’t mean it should—at least not without our clinical brain in the driver’s seat. The good news? You can absolutely use AI to make your documentation faster, smoother, and less soul-sucking—without risking ethical disasters or getting side-eyed by insurance reviewers.

This guide is your therapist-to-therapist, no-BS walkthrough of how to use AI to help with progress notes—ethically, effectively, and without losing your voice (or your license). We’ll talk consent, compliance, what insurance actually wants to see, and how to prompt AI without sounding like a robot yourself.

Spoiler: You still have to do a little work. But if AI can help you get out of the note vortex and back to, you know, living your life? Let’s do it.

Can AI Really Help Therapists with Notes?

Let’s cut to the chase: yes, AI can help—but only if we use it like a seasoned therapist uses a white noise machine or a coffee IV drip. It’s not magic. It’s a tool. And like any tool, it can build something brilliant or cause chaos, depending on how it’s wielded.

What AI can do:

• Summarize a session when you’re too brain-fried to remember what your own name is, let alone what happened with your 2:00 PM client.

• Format a jumbled dictation into something resembling a coherent SOAP, GIRP, or DAP note.

• Translate the inner monologue of, “Client cried a lot, we did some deep stuff” into something your insurance audit team won’t cringe at.

What AI cannot and should not do:

• Diagnose your client. (That’s your job, friend.)

• Detect risk, assess safety, or pick up on subtle clinical nuance that you noticed from a raised eyebrow and a half-swallowed sigh.

• Replace your actual therapeutic voice with a stream of generic, soulless phrases like “Client appeared to be in moderate distress and engaged in appropriate affective regulation strategies.” (Unless you like that sort of thing… in which case, carry on.)

Used wisely, AI can be your admin sidekick—your note-taking co-pilot who doesn’t get burnout or eat the last granola bar in the breakroom. But it’s still your name on the bottom of the note, which means your judgment, ethics, and clinical acumen have to stay front and center.

Ethical Considerations When Using AI in Clinical Documentation

Before you cozy up to your AI note buddy and let it summarize your session about childhood trauma and avoidant parts, let’s take a pause. Just because AI is trendy doesn’t mean it gets to skip the ethics consult. As therapists, we know better than to dive into any shiny new thing without first asking: “What’s the clinical and legal liability here?”

So here it is—your ethical gut-check before inviting AI into your documentation process.

First Things First: HIPAA Is Still a Thing

If you’re using any AI tool that processes client information, it must be HIPAA-compliant. That means no ChatGPT (unless you’re paying for the Business or Enterprise versions under a signed BAA), no random note generator you found on Instagram, and absolutely no copy-pasting identifiable client content into a browser-based tool without protections in place.

If the AI platform doesn’t explicitly state that it’s HIPAA-compliant and doesn’t offer a Business Associate Agreement (BAA), you shouldn’t be using it with real client data. Period. Keep your license cozy and intact.

The Note Is Still Yours (Yes, Even if AI Wrote It First)

Using AI doesn’t magically shift legal or clinical responsibility. That note? Still has your name on it. That means you’re still accountable for the accuracy, appropriateness, and clinical integrity of what it says—even if AI wrote the first draft. Think of AI like an eager intern with zero boundaries: helpful, but in need of supervision.

You need to review, edit, and personalize anything AI generates. Otherwise, you risk documenting things that didn’t happen, missing important risk elements, or sounding like your notes were written by a very polite alien.

Should Clients Know You’re Using AI?

This one’s murky. If AI is integrated into your EHR or practice management system with HIPAA compliance in place, there’s no ethical requirement (as of now) to disclose AI use. But if you’re using a third-party tool or app, and especially if it involves uploading session data or transcriptions, transparency might be the most ethically aligned path—especially for clients who value data privacy and consent.

You don’t have to say, “Hey, I fed your existential breakdown into a robot,” but something like, “I use secure software that may support documentation using AI tools, all within HIPAA guidelines,” goes a long way in keeping your practice values-aligned.

Don’t Let Efficiency Compromise Clinical Integrity

Yes, AI can be helpful. Yes, it can save you time. But no, it should not become a shortcut that disconnects you from your clinical thinking. The minute your notes stop sounding like your voice—or worse, stop reflecting the actual client experience—you’re no longer documenting ethically or therapeutically.

Bottom line? AI is a support tool, not a substitute for clinical discernment, ethical standards, or compassionate presence. Use it wisely, and it can help lighten the admin load. Use it poorly, and it’s just another liability with better grammar.

Client Consent Language for AI-Assisted Documentation

If you’re using an AI tool that includes voice dictation, live transcription, or digital scribing—even with HIPAA compliance in place—it’s wise to let your clients know. While not always legally required, this transparency aligns with our ethical values of informed consent and client autonomy.

Client Consent for the Use of a Digital Scribe Tool

So you’ve found the perfect AI note tool, polished your prompts, and are feeling good about your streamlined documentation game. But now comes the question: How do I actually talk to clients about this without sounding like a robot overlord or a HIPAA horror story?

Fear not. I’ve got you.

Click below to grab a ready-to-use, client-friendly Digital Scribe Consent Handout—written in real-person language, not legalese. It covers what the tool does (and doesn’t do), how data is protected, and reminds clients that they’re always in charge of whether it’s used. Because informed consent isn’t just a checkbox—it’s a conversation.

👉 Click below to download the Client Consent for the Use of a Digital Scribe Tool

Use it as-is, or tweak it to match your practice vibe. Bonus: it’s written to be warm, transparent, and totally revocable—because your clients deserve clarity, not confusion.

(Pro tip: Print it, e-sign it, or make it a standard part of your intake packet if you’re using AI tools regularly.)

⚖️ Disclaimer: This handout is intended for informational and practice-support purposes only. I am not a lawyer, and this is not legal advice. Please consult with your legal or compliance team to ensure the language aligns with your state regulations, practice policies, and licensure board requirements.

Insurance Standards Still Apply—Don’t Let AI Water Down the Clinical Quality

Here’s the thing: your AI-generated note might sound super polished. It might even say something like “Client demonstrated improved adaptive functioning via introspective engagement.” And sure, that sounds fancy. But does it actually say what happened? Can it back up the CPT code you billed? Will it pass a records request from insurance companies without a raised eyebrow?

If your beautifully phrased note doesn’t meet medical necessity or clearly tie back to the client’s treatment plan, it’s basically a literary shrug. And insurance companies don’t reimburse based on vibes.

AI Can’t Replace Medical Necessity (But You Can Train It to Speak the Language)

When you’re working with insurance, your notes need to show:

• Why the client is coming to therapy (aka functional impairment)

• What you’re doing about it (interventions)

• How the client is responding (progress, resistance, or maintenance)

• Where it’s going (plan, next steps, risk considerations)

AI doesn’t know if your client was spiraling into dissociation or just zoning out because they skipped lunch. That’s your clinical eye. So even if you use AI to clean up your rough note or structure your session summary, you have to make sure it speaks fluent “insurance justification.”

Keep Your Note Structures Strong (SOAP, DAP, GIRP—Whatever Works for You)

AI can help format your notes, but you still need to give it clear input. If you ask it to “write a note for my client with depression,” don’t be surprised when it spits out something that reads like a generic Wikipedia summary with a therapy buzzword or two.

Instead, feed it specifics:

• “Client presented as tearful and reported decreased motivation. We explored cognitive distortions related to self-worth and practiced reframing techniques. Client engaged and showed some insight into the impact of past trauma on current functioning.”

• That input will give you a much stronger draft to work with—and one that actually reflects your session and the CPT code you billed.

Whether you use SOAP, GIRP, or your own special Frankenstein hybrid (we all have one), make sure AI doesn’t flatten the note into sterile gibberish. You still need to clearly hit the elements that justify treatment.

Don’t Let Clinical Depth Get Lost in the Algorithm

AI loves patterns. It’s trained to say what it thinks therapists say in notes—which means you’ll often get the same tired phrases on repeat. “Client appeared engaged.” “Therapist provided supportive environment.” “Session focused on treatment goals.” Yawn.

If your notes all start to sound like they were written by a therapist NPC in a video game, it’s time to re-engage your voice. AI can help structure and polish, but it can’t replace the nuance of a client shifting in their seat when they finally speak their truth—or your decision to slow the session down and hold space instead of jumping into solutions.

Pro-tip: Audit Your AI Notes Every So Often

Here’s your permission slip to be a little neurotic: every few months, review your AI-assisted notes. Are they still:

• Tied to treatment goals?

• Clinically accurate?

• Free of vague filler?

• Defensible in an audit?

If the answer is “ehhh,” go back and fine-tune your process. Your future self (and possibly your licensing board) will thank you.

How to Effectively Use AI to Write Progress Notes

Alright, so you’re sold on the idea that AI can help—not replace—but help with your documentation. The question now is: how do you actually do this without ending up with a Franken-note full of jargon and random clinical platitudes? The key is in the process—and yes, it involves more than just yelling “Write my notes!” into the void.

Step One – Gather Your Raw Material

Before AI can help, it needs something to work with. That means you still need to jot down the essentials:

• What the client said or focused on

• Your interventions (modalities used, skills taught, insights explored)

• How the client responded (emotionally, behaviorally, insight gained, resistance, etc.)

• Your clinical assessment and any risk considerations

• What’s next (homework, focus for next session, referrals, safety planning)

You can do this in shorthand, bullet points, or a quick post-session voice memo to yourself—just make sure it’s HIPAA-compliant and kept secure.

Step Two – Prompt AI Like a Clinician, Not a Casual User

This is where the magic happens. Instead of typing something vague like “write a note for a therapy session”, talk to your AI like a clinical assistant who needs direction.

Try something like:

“Using the following session summary, draft a SOAP note with appropriate clinical language for insurance documentation: Client reported increased anxiety related to job stress. Therapist used CBT to identify cognitive distortions and practiced a thought record. Client was engaged and reported some insight into how their thoughts escalate their distress. No current safety concerns. Plan is to continue practicing reframing and introduce behavioral activation.”

Give it just enough structure to generate something useful without overwhelming it with fluff. Think of it like giving a great intern very detailed instructions—because AI is smart, but it doesn’t know your client, your voice, or your style unless you teach it.

Step Three – Edit Like the Ethical Badass You Are

AI gives you a starting point. Your job is to make sure it:

• Sounds like you

• Reflects what actually happened

• Connects to the treatment plan

• Covers your ethical and legal bases

Tweak the language to reflect your tone, clarify anything vague, and make sure your interventions and assessments are accurate. If the AI wrote something that sounds impressive but didn’t actually happen—cut it. Don’t let a fancy phrase tempt you into fiction.

Step Four – Drop It Into Your EHR and Move On with Your Life

Once you’ve reviewed and personalized your note, drop it into your documentation system and hit that glorious “complete” button. You’ve done your due diligence, upheld clinical standards, and saved your nervous system from note fatigue. Celebrate accordingly (we recommend snacks or petting something fluffy).

Therapist Scripts for Prompting AI Tools (with Disclaimers!)

AI isn’t a mind reader. It doesn’t know the difference between an emotionally transformative session and a casual check-in about meds unless you tell it. The good news? You don’t need to be an AI engineer to get high-quality notes—you just need the right prompts.

Below are ready-to-use therapist scripts (aka prompts) you can copy, paste, and customize to get insurance-friendly, clinically sound drafts. Bonus: they don’t sound like a robot wrote them after binge-watching a season of Grey’s Anatomy.

The Safe-Use Disclaimer (Seriously, Don’t Skip This)

Before we get into the juicy prompts, let’s be crystal clear:

Never enter PHI (Protected Health Information) into a non-HIPAA-compliant AI tool. That means no names, dates of birth, diagnosis codes, or anything that could identify your client unless you’re using a platform with a signed Business Associate Agreement (BAA) and full HIPAA safeguards.

If you’re using a tool like standard ChatGPT or other open-access platforms, anonymize everything:

• Call them “Client”

• Leave out or disguise sensitive details

• Keep it general and clinical, not personal or narrative-based

Cool? Cool.

Script #1 – For a Standard SOAP Note

“Using the SOAP note format, generate a progress note for the following therapy session:

Client presented with increased anxiety related to family conflict. Therapist utilized CBT and IFS-based techniques to explore core beliefs and regulate emotional responses. Client showed moderate insight and practiced a reframing exercise. No current safety risks noted. Plan is to continue emotional regulation work and revisit family boundary-setting next session.”

Script #2 – For a Brief Check-In Session (e.g., 90832)

“Write a brief SOAP note for a 30-minute session focused on medication adjustment support and stress check-in. Client reported mild depressive symptoms and difficulty with sleep. Therapist provided supportive listening, tracked mood trends, and encouraged sleep hygiene practices. No suicidal ideation reported. Plan to monitor symptoms and coordinate with prescriber as needed.”

Script #3 – For a GIRP-Style Note

“Create a progress note in GIRP format based on this summary:

Client focused on improving self-esteem and reducing social anxiety. Therapist used strengths-based interventions and guided a values exploration exercise. Client was engaged, shared reflections on past relationships, and showed willingness to challenge negative self-talk. Plan is to assign a journaling prompt and begin social exposure exercises.”

Script #4 – For a Trauma-Focused Session

“Generate a SOAP note with trauma-informed language based on this session:

Client discussed recent trauma triggers related to a past abusive relationship. Therapist used grounding, psychoeducation, and somatic resourcing. Client was tearful but regulated, practiced containment, and reported some relief. Therapist assessed risk—no SI/HI. Plan includes continued use of somatic tools and introduction of trauma narrative pacing.”

Script #5 – When You’re Fried and Need a Jumpstart

“Turn this mess into a SOAP note that makes sense:

Client cried a lot. We talked about stuff from childhood. I used IFS and validation. They seemed calmer by the end. Nothing scary came up. I want to work on attachment stuff next time.”

(Hey, we’ve all been there.)

These prompts can act like your clinical sous-chef: prepping the ingredients so you can come in, make the finishing touches, and serve something solid. Just remember: you are still the chef. AI can prep the carrots, but it doesn’t know if your client is allergic to soup metaphors.

💾 Bonus Download: Your AI Prompt Cheat Sheet (Because You Deserve Fewer Tabs Open)

Look, we’ve all had that moment: staring at your EHR, brain mushy, fingers hovering over the keyboard like you’re about to compose your next masterpiece… but all that comes out is, “Client talked about stuff. I nodded a lot.”

That’s where this comes in.

Click below to grab your AI Prompt Cheat Sheet for Therapists—a printable (or bookmarkable) one-pager packed with example scripts for SOAP, DAP, GIRP, trauma-focused sessions, and even those “my brain is done” moments.
🧠 Designed to help you write strong, insurance-ready notes without sounding like a robot.

📥 [Click below to download your free AI Prompt Cheat Sheet]
Use it. Reuse it. Stick it to your wall like the ethical documentation pep-talk it is.

Popular AI Tools for Progress Notes (That Are Actually Built for Therapists)

By now, you might be wondering: Okay, cool—but what platforms are therapists actually using that won’t get me sued or haunted by a board complaint? Excellent question.

Not all AI is created equal, and definitely not all AI is created with therapists (or HIPAA) in mind. Below are some of the more popular, therapy-focused options currently on the radar—some buzzy, some quietly doing the work behind the scenes.

Berries AI (My Preferred Platform—And the One I Use)

The vibe: Think voice note meets AI scribe. Berries AI is making waves for allowing therapists to dictate session summaries (HIPAA-compliant) and receive a clean, structured note—often in your preferred format (SOAP, GIRP, DAP, etc.).

Why therapists like it (and why I use it):

• 🗣 Dictation saves time (goodbye, typing hand cramp)
• 🔐 HIPAA-compliant with a signed BAA
• 🧠 Offers note formatting + insurance-friendly phrasing
• 🎯 Customizable language based on your voice, style, and clinical preferences

Things to know:
It’s not a “click and forget” tool—you still need to read, edit, and ensure the note reflects what actually happened in session. But it’s miles ahead of typing from scratch. For me, it’s the perfect combo of ease, ethics, and accuracy. If you’re looking to test the AI waters without getting lost at sea, Berries is a solid starting point.

Want to try it? I’ve got you.

Use my referral link to sign up 👉 https://heyberries.com/?via=7671
And get 50% off your first month with this exclusive code:
🧠 Coupon Code: Jennifer50Discount

Whether you’re deep in burnout territory or just curious about what tech can do for your workflow, Berries might be the game-changer you didn’t know you needed. (You’re still doing the work—it’s just helping carry the clipboard.)

Blueprint

The vibe: A powerhouse AI assistant for mental health pros, Blueprint automates progress notes, drafts treatment plans, and offers in-session and post-session insights that actually feel helpful—not intrusive.

Why therapists like it:

• Generates progress notes and smart treatment plans fast

• Provides pre-session summaries, live session support, and follow-up suggestions

• HIPAA-compliant and SOC 2 Type II certified

• Clean, therapist-friendly interface (without the “tech bro” energy)

Things to know: Offers a free trial, then shifts to a paid model based on session volume (starting at around $39/month). Great for therapists who want a full AI workflow companion.

Clinical Notes AI

The vibe: A practical and lightweight AI tool designed to help healthcare professionals streamline documentation. It records sessions, transcribes conversations, and helps create clinical notes—often through a Chrome extension or integrated platform.

Why therapists like it:

• Offers real-time transcription during sessions

• Converts spoken content into structured notes

• Supports integration with EHR platforms

• Designed to save time while capturing session nuance

Things to know: While convenient, always double-check for HIPAA compliance, obtain client consent if recording, and ensure any Chrome extension use aligns with your security policies. It’s a powerful tool, especially for clinicians looking for low-lift support with documentation.

DeepScribe

The vibe: AI that listens during sessions (with consent), transcribes, and generates notes automatically. More integrated with EHRs and often used in medical/psychiatric settings, but gaining traction in therapy circles.

Why therapists like it:

• Voice-to-note without post-session dictation

• High accuracy in capturing natural conversation

• Integrates with some practice management systems

Things to know: May feel a little more “surveillance-y” to some clinicians and clients. Informed consent is a must. Best suited for folks who are comfortable with AI being present during the session.

TherapyNotes + AI Plug-ins (Coming Soon / Beta)

The vibe: Traditional EHRs are catching up. Some, like TherapyNotes, SimplePractice, and TheraNest, are starting to build or integrate AI-based note helpers. Some of these are still in beta or third-party integrations (Zapier-style).

Why therapists are excited:

• Seamless integration with what you’re already using

• Reduces note duplication and post-session admin

• Often backed by solid HIPAA compliance infrastructure

Things to know: Features vary, and some are more predictive-text than full AI assistant. Watch for future rollouts if you’re already using one of these platforms.

ChatGPT + HIPAA-Compliant Wrappers

The vibe: Using ChatGPT—but safely. Some platforms (e.g., Jasper Health, Nabla, Tali AI) wrap OpenAI models in HIPAA-compliant environments, offering a secure way to get that ChatGPT power without risking a privacy violation.

Why therapists like it:

• Flexibility and advanced natural language generation

• Cheaper than some industry-specific tools

• Can be tailored with prompts and templates

Things to know: Make sure the wrapper offers a signed BAA and clear HIPAA protocols. If not, it’s just a shiny liability machine.

DIY + Voice-to-Text Combo (Low-tech, Still Effective)

The vibe: Use your phone’s dictation app (Apple Notes, Otter.ai, etc.) to summarize a session, then drop the cleaned-up text into an AI platform for formatting. It’s more hands-on, but also more budget-friendly.

Why therapists use it:

• No monthly subscription

• Great for those who just want a little structure, not a full platform

• Customizable and flexible

Things to know: HIPAA compliance is on you. Store transcriptions safely, anonymize data, and never use public tools with client details.

No matter the tool, the same rule applies: AI helps with the heavy lifting, but you still steer the ship. If it’s not HIPAA-compliant, ethically sound, or clinically accurate—it’s not worth it, no matter how cool the tech is.

Red Flags and Common Mistakes to Avoid

Just because AI is your new BFF doesn’t mean it’s incapable of ghosting you—ethically, clinically, or legally. These are the red flags and oops-moments you’ll want to dodge like that one client who always cancels last-minute and insists it’s “just the retrograde.”

Copy-Pasting Without Reading = A Lawsuit Waiting to Happen

Let’s start with the big one: copying an AI-generated note without reading it first. We get it. You’re tired. You’re behind. But if you paste a note into your EHR without reading it like a hawk, you’re asking for trouble.

You might accidentally:

• Chart an intervention you didn’t actually use

• Document progress that wasn’t made

• Miss something ethically or clinically critical (e.g., risk not mentioned, client resistance glossed over)

Always, always read and edit the note before finalizing it. AI doesn’t know what you meant—it just knows what sounded right statistically.

Overusing Vague, Pretty Words That Say Nothing

AI loves a good fluff sentence:

• “Client appeared engaged.”

• “Therapist provided a supportive environment.”

• “Session focused on treatment goals.”

Cool. But what did you actually do? What goal? What skill? What progress? These phrases might fly in a rush, but if you’re audited—or worse, in a legal case—you’ll wish you were more specific.

AI might give you a starting point, but you have to add the meat. Otherwise, you’re serving insurance companies a beautifully frosted cake with no filling—and spoiler: they don’t like empty carbs.

Using AI Without HIPAA Compliance (a.k.a. Playing with Fire)

We’ve said it before, but it bears repeating: if it’s not HIPAA-compliant, it’s off-limits for client data. Even if you love ChatGPT, the free version isn’t a secure place to drop therapy details. And yes, even if you remove the client’s name, the session story itself can still be identifying.

Unless your AI platform has a signed Business Associate Agreement (BAA) and meets HIPAA security standards, it’s just not worth the risk.

Letting Your Notes All Start to Sound the Same

AI can fall into “note déjà vu” territory. If you’re noticing that your last five notes all start with “Client appeared in a mildly anxious state and engaged in discussion around…” you might need to shake it up.

Progress notes should reflect each client’s individual presentation and specific therapeutic experience. Letting AI shape your voice too much can flatten your notes and rob them of clinical richness (and make you look checked-out if someone’s reviewing them).

Relying on AI to Interpret Clinical Nuance

AI can write a lovely sentence about cognitive reframing. What it can’t do is catch the micro-shift in a client’s body language when they bring up their father for the first time or know that silence in today’s session was pregnant with grief, not disengagement.

That’s your job.

Use AI for support—but don’t outsource your clinical intuition, ever.

AI and the Future of Therapist Workflow

Let’s face it: therapists didn’t get into this field for the paperwork. And yet, somewhere between state board requirements, insurance audits, and treatment plans written in your car with 3% battery left, it started to feel like documentation was the job—and therapy was just the thing you did in between.

AI has the potential to shift that.

Not by replacing us. Not by writing every word for us. But by lightening the admin load just enough to help us reconnect with the part of this work that actually matters: being present, attuned, and human.

Less Burnout, More Bandwidth

When used wisely, AI can:

• Cut down the time spent agonizing over how to phrase your intervention

• Give you a starting draft that you can polish instead of a blank screen to battle

• Offer note templates and formatting so your brain doesn’t have to toggle between “therapist mode” and “pretend-you’re-an-insurance-lawyer” mode

For solo practitioners, this can be the difference between spending your Friday night catching up on a dozen notes or—radical idea—having a life.

Tech Won’t Replace Therapists—But Therapists Who Use Tech Might Thrive

AI isn’t here to replace the relational depth or clinical intuition you bring to your work. It can’t. What it can do is make room for more of that—by giving you time back, reducing cognitive fatigue, and keeping your documentation sharp, ethical, and audit-proof.

Therapists who learn to use AI as a support tool—not a shortcut—may find they’re less drained, more efficient, and better able to scale their practice or simply breathe a little easier.

Proceed With Curiosity (and Boundaries)

You don’t need to use every tool. You don’t have to jump on every beta waitlist. But stay curious. Experiment. Find what works with your workflow and aligns with your values. This isn’t about becoming a robot—it’s about using the tools available to do your job with more humanity, not less.

And if all AI ever does is help you get your Friday notes done on Thursday? That’s still a win.

It’s About Support, Not Shortcutting

Let’s normalize something right now: therapists are human. We are caring, attuned, compassionate professionals—and sometimes we’re also overwhelmed, overbooked, and mentally done by Wednesday. AI isn’t here to “fix” us. It’s not a crutch, and it’s definitely not a replacement. It’s support—plain and simple.

Used with intention, AI can sit quietly in the background of your practice like that one friend who folds your laundry while you’re crying over a deadline. It’s not trying to do your job—it’s just trying to make it a little easier to show up fully for it.

This isn’t about taking shortcuts or detaching from your clinical voice. It’s about finding ways to reduce burnout, reclaim your time, and stay ethically grounded while keeping up with the unavoidable realities of documentation. It’s about auditing your use regularly, staying curious about your tools, and remembering that the work—the real work—still happens in the room with your client.

So if AI helps you get there with a little more energy and a little less dread? Beautiful. Use what works, skip what doesn’t, and keep doing what you do best: showing up human.

Your New Favorite Handout—Because Grad School Didn’t Teach This

Let’s be real: grad school taught us how to hold space, not how to write a progress note that could survive a records request from Aetna. That’s why I put together this therapist-friendly handout—a cheat sheet of everything insurance actually wants to see in your documentation, plus ready-to-use templates in SOAP, GIRP, and DAP formats and clinically solid phrasing for medical necessity, 90837 justification, and scaling.

Whether you’re an intern, a supervisor, or a slightly crispy solo practitioner trying to stay caught up, this handout’s for you. Use it to:

• ✅ Audit your own notes when imposter syndrome kicks in
• ✅ Train new clinicians or associates without reinventing the wheel
• ✅ Reassure yourself you’re not missing something critical (you probably aren’t—but now you’ll know for sure)
• ✅ Make your notes sound strong enough for insurance without sounding like a robot wrote them

🧠✨ Click below to download the Therapist Handout – Documentation Essentials + Templates.

(Pro tip: Keep it in your bookmarks, desk drawer, or tattooed on your forearm. No judgment.)

Inside the handout, you’ll get:

• Essential elements for insurance-compliant notes (so your SOAP actually says something)
• Medical necessity phrase bank that makes your notes audit-proof without sounding like a textbook
• 90837 justification phrases that explain why you really needed that full hour
• Scaling examples for participation and progress (yes, the 1–10 kind, but with feeling)
• Templates for SOAP, GIRP, and DAP in plain language that still meets the clinical bar

In short? It’s the documentation sidekick you didn’t know you needed—and now won’t want to live without.

Let the Notes Work for You, Not on You

If you’ve made it this far, first of all—gold star. You’re clearly committed to doing documentation differently: smarter, more ethically, and with your sanity intact. This isn’t about cutting corners. It’s about cutting through the noise and giving yourself the same grace you give your clients.

Because here’s the real win: when your notes are handled with care, structure, and just enough AI support to make them manageable, you get to show up more fully in the room. You’re not worrying about how you’re going to phrase something three hours from now. You’re here, with your client, in the moment. And that’s where the good stuff happens.

Use what works. Discard what doesn’t. Tweak, trial, and try again. Whether AI becomes your favorite tool or just a once-in-a-while pinch hitter, let it be a support—not a replacement, not a stressor, and definitely not a source of shame for being a human therapist in an imperfect system.

We all deserve workflows that don’t burn us out.

We all deserve time back to live our lives.

And we all deserve to write notes that reflect the depth of our work without sacrificing our evenings, weekends, or one remaining brain cell.

Now go forth and document like the clinically sound, slightly sarcastic, ethically solid badass you are.

Written by Jen Hyatt, a licensed psychotherapist at Storm Haven Counseling & Wellness in Temecula, California.

---

Disclaimer

This blog post is intended for informational and educational purposes only and reflects the author’s perspectives and experiences as a mental health professional. It is not a substitute for formal training, supervision, or individualized clinical guidance. Therapists are encouraged to consult their own professional resources, supervisors, or peers when applying concepts to their practice.

Affiliate Disclaimer

Heads up: This post includes an affiliate link for Berries AI. That means if you decide to try it out and make a purchase through the link, I may receive a small commission—at no extra cost to you.

I only recommend tools I genuinely believe can support our work as therapists, and Berries AI is one I personally use in my own practice. It’s been a helpful support in cutting down documentation time while still staying clinically sharp and ethically grounded.

If you’re curious and want to give it a try, you can use my referral link 👉 https://heyberries.com/?via=7671
And snag 50% off your first month with the code:
🧠 Jennifer50Discount

As always, feel free to explore what works best for you. No pressure, no shady stuff—just transparency and a tool I’ve found helpful enough to share.