Delta · Blog
31 articles
How to write an EHCP professional report that a local authority or tribunal can use. Needs by area, SMART outcomes, quantified provision, a template and a fictional example.
In child psychiatry, one consultation brings together the child, one or two parents and often the school's view, sometimes with a treatment to monitor. Here is how to keep a clear note on each of these points, with the French legal framework, a template to copy and a completed example.
IPT is a brief, structured therapy, and its notes should follow the same logic, phase by phase. Here is what is worth writing down at each stage, a template to copy and a fully written fictional session.
A mindfulness session note tracks practices, how regularly the patient trains at home and how they relate to their thoughts. Here is what to write, in individual sessions and in groups, with a template and a completed example.
In Acceptance and Commitment Therapy, the session note does not only track symptoms. It keeps track of how the patient relates to their thoughts and emotions, and of what they do for what matters to them.
The first addiction consultation describes substance use, assesses the risks and builds a care plan with the person. Here is a full template, a fictional filled-in example and what goes, or does not go, in the letter to the GP.
In addiction care, a session note is only useful if it lets you compare the months with each other. Here is what to note at each session, how to measure use with the same units, a ready-to-use template and a completed example.
A patient asks for their file, or a dispute is looming. Here is what the law lets the patient obtain depending on your status, how to reply on time, and how to write notes you can show without worry.
SOAP, DAP, BIRP and their variants are ways of sorting a session note into a few fixed sections. To see what really changes, we wrote the same session in each format, then looked at what French, Belgian and Swiss rules require.
The first session is for understanding the person's request, history and situation, without turning it into an interrogation. Here is a complete intake interview template by area, with versions for children, adolescents and neuropsychological assessment, and what the 2021 French code of ethics says.
Session notes, tracking the work, preparing the next session, ChatGPT. What AI can do for a therapist, and what not to give it.
Reports, letters, follow-up, ChatGPT. What AI can do for a psychiatrist, what not to give it, and where to start.