Cognitive remediation session note template, with a worked example

A cognitive remediation session note is the short record written after each session that links what was worked on (function, exercise, level, strategy) to the functional goals set from the neuropsychological assessment and the patient's own plans. It is what lets you show, at the progress review and at the end of the programme, what changed in daily life and not only in the exercises.

Why the session note matters so much in cognitive remediation

The training material of the French Centre ressource de réhabilitation psychosociale lists six steps: clinical and cognitive assessment, assessment of functional impact, goal setting, remediation (paper and pencil or computerised), home tasks, and review. Without session notes, the end of programme review compares two sets of tests and says nothing about the path in between.

It helps you adjust the level from one session to the next, and helps the team (psychiatrist, nurse, occupational therapist) know what to support in daily life. The same material says programmes also aim to reduce functional difficulties with meals, travel, housekeeping, paperwork, leisure and social relationships. That is where the note should look.

If you are starting from scratch, begin with the baseline report: our neuropsychological assessment report template gives the base the goals rest on.

What a cognitive remediation session note should contain

1. The functional goal

Write the number and wording of the goal as agreed with the patient ("G2: write the weekly shopping list alone"). A remediation goal does not have to be cognitive. An unsigned 2011 Psychiatric Times article, which cites Medalia and colleagues among others, says it: "Goals do not need to be cognitive". One of its examples is understanding the doctor's medication instructions.

2. The function targeted and the link to the assessment

Name the function (sustained attention, flexibility, working memory, planning, emotion recognition, theory of mind…) and restate in one line what the baseline assessment showed. This avoids exercises that are pleasant but do not serve the goal.

3. Exercises, module and level

Module, exercise name or number, level, any change made (see the FAQ for manualised programmes). For a free exercise, one sentence is enough.

4. Observed performance and level of support

What you saw, not a global judgement: type of errors, time taken, self-corrections, and above all the support given: independent, verbal prompt, step by step guidance, demonstration. This is the most telling marker from one session to the next.

5. Strategies and aids

The techniques listed by the Centre ressource (after Wykes et al., 2007) give a shared vocabulary: verbal guidance, reducing information, breaking the task down, reminder notes, repetition, grouping information, planning the steps. Note the strategy offered, the one the patient actually used, and any external aids (diary, alarms, list, prompt card).

6. Metacognition

What the patient says about how they went about it: what worked, what got in the way, their prediction before the task and their view after. A quoted sentence is worth more than an interpretation.

7. Transfer to daily life

The real situation chosen, then what happened (see the FAQ). The same Psychiatric Times article says remediation is best paired with a psychosocial rehabilitation programme, otherwise gains are unlikely to transfer to real-world functioning and are hard to maintain.

8 and 9. Observations and next steps

Fatigue, motivation, events weighing on the session, kept factual. Then the home task, concrete and dated, and the decision for the next session.

The programmes: what the sources say

The Centre ressource material groups the main French-language programmes into two families.

• Neurocognition: CRT (Delahunty and Morice, 1989; Amado et al., 2008), RECOS (Vianin, 2013), Cognitus et Moi (Demily et al., 2016), NEAR (Medalia, 2002).
• Social cognition: Gaïa (Gaudelus et al., 2016), RC2S (Peyroux and Franck, 2014), SCIT (Penn and Roberts, 2009), ToMRemed (Bazin et al., 2010), IPT (Brenner et al., 1992), MCT (Moritz et al., 2010).
• General length: according to the same material, programmes last "a few months, with 1 to 2 sessions a week plus home tasks".
• CRT at Tours University Hospital: according to the service leaflet, an individual programme of paper and pencil exercises over 4 months, with two one-hour sessions a week: 8 flexibility sessions, 16 memory and 16 planning (40 in all), with a neuropsychological assessment at the start and another at the end.
• NEAR (group presented by the Centre ressource): closed group of 6 to 8 participants, two two-hour sessions a week, about 31 sessions over about 4 months, with a neurocognitive assessment and an individual interview before and after the group.
• CIRCuiTS: a computerised programme which, according to the Centre ressource, focuses on developing metacognition, with activities set in a virtual village.

In the note, only the "exercises" section changes with the programme. The rest of the template stays the same, so notes remain comparable if you use several programmes.

Cognitive remediation session note template (copy and paste)

Header

• Patient: initials or internal ID
• Date, session no.: … / planned …
• Programme and module: … (or "individual programme")
• Format: individual / group; paper and pencil / computerised; length …
• Clinician: name, title

1. Functional goal(s) for this session

• G…: wording as agreed with the patient
• Baseline reminder (one line): …

2. Review of the between-session task

• Planned task: …
• Done: yes / partly / no. What the patient says: "…"
• Obstacle: …

3. Function targeted and exercises

• Function: …
• Exercise 1: name or number, level, change made
• Exercise 2: …

4. Observed performance

• Successes and type of errors: …
• Level of support: independent / verbal prompt / step by step / demonstration
• Change since last session: …

5. Strategies and aids

• Strategy offered: …
• Strategy used spontaneously: …
• External aids: …

6. Metacognition

• Patient's prediction before the task: …
• Their analysis afterwards: "…"

7. Planned transfer to daily life

• Real situation: where, when, with whom
• Link to goal G…: …

8. Observations

• Fatigue, motivation, state on the day: …
• To share with the team (with the patient's agreement): …

9. Between-session task and next steps

• Task: …, to do by …
• Next session: keep / raise the level / change strategy, because …

Short progress review or end of programme template

It draws on the session notes and refers to the final neuropsychological assessment, which remains a separate document.

• Setting: programme, dates, sessions planned and attended, absences
• Baseline reminder: strengths, difficulties, impact on daily life (three to five lines)
• Functional goals: for each goal, starting point, current situation as described by the patient and those around them, achieved / partly / not achieved
• Progress in sessions: levels reached, reduced support, strategies acquired
• Transfer: real-life situations where the strategy is used without a prompt
• Metacognition: what the patient now knows about how they function
• Final assessment results: refer to the neuropsychological report rather than copying it
• Recommendations: continue, another programme, handover to the team, aids to keep
• Feedback: date of feedback to the patient and recipients of the document, with their agreement
• Document footer (France): date, name, title, registration number, professional contact details, signature, recipient and purpose (article 18 of the French Code of Ethics for Psychologists)

Fully completed fictional example

Invented case, not based on any real person.

• Patient: Mr L., 34, ID 0412
• Date, session no.: 6 November, session 14 of 40
• Programme and module: CRT, planning module
• Format: individual, paper and pencil, 1 hour
• Goal: G2, "do my weekly shopping with a list, without forgetting the essentials and without going back through the shop twice"
• Baseline reminder: slow planning, tends to start without a plan, good visual memory
• Task review: list written for Saturday's shopping, partly done. "I made the list but in no order, I had to go back to the chilled aisle."
• Exercises: route planning on a map (level 3, map simplified to 8 places); sorting 20 items into categories
• Observed performance: correct route on the second attempt; one sequence error on the first, self-corrected after checking; sorting done without help, faster than in session 12
• Level of support: one verbal prompt ("look at the whole map before you start"), then independent
• Strategies: offered, "plan the steps before acting" and group items by aisle; used spontaneously for sorting, not yet for the route
• Metacognition: before, "I'll get it quickly"; after, "when I rush I make mistakes, checking helps me"
• Planned transfer: Saturday's list arranged by aisle, following the layout of his usual shop, using the plan drawn together
• Observations: a little tired by the end, good motivation. To share with the key nurse (agreed): support the aisle-ordered list
• Between-session task: aisle-ordered list before Saturday, note whether he had to go back
• Next session: keep level 3 for the route, move to level 4 for sorting; review Saturday

Common mistakes

• Noting the exercise without the goal: six months later, nobody knows why it was chosen.
• Writing "good session" or "improving": use the level of support and the type of error, which can be compared across sessions.
• Skipping the home task review: it is the first trace of transfer, and the one most often missing.
• Interpreting rather than quoting: one sentence from the patient about how they worked says more than "good insight".
• Sharing everything with the team: only what is strictly necessary (see the FAQ).
• Promising effects: write what was observed, not what the programme is supposed to achieve.

Checklist before closing the note

• The functional goal is named and numbered.
• Module, exercise and level can be identified.
• The level of support is noted.
• The strategy actually used (not only the one offered) is described.
• The note includes one sentence from the patient about how they worked.
• The between-session task is concrete, dated and linked to the goal.
• The decision for the next session is written, with its reason.
• What will be shared with the team is limited to what is needed and the patient knows.
• The note is dated and carries your name (we advise this for every note).

Confidentiality, records and retention

In France, neuropsychologists are psychologists. The French Code of Ethics for Psychologists (2021 version) states that professional secrecy covers everything the psychologist learns in the course of their work (article 7, within the limits set by the Penal Code), and that psychologists collect, process, file and archive their notes and activity data in a way that protects privacy and secrecy (article 23). Article 18 lists what documents issued by a psychologist must carry (see the footer of the progress review template above): apply it to any review or summary you send out.

Retention periods depend on where you practise. We advise setting a written retention period for your practice and checking it against the rules of your country, professional body or, in Switzerland, your canton. In Belgium, we advise checking with the Psychologists' Commission.

Why Delta fits cognitive remediation

In the two programmes described above, that means 31 to 40 notes for the same patient, which only make sense read together. Delta is the clinical assistant that keeps the memory of each patient. It transcribes what is said in session, or you dictate your observations afterwards. It generates the session report (short summary, detailed summary, topics for next session) and updates the patient record with a summary of care and the goals being tracked: at the progress review, how each goal has evolved is in one place.

Delta also drafts your assessments and letters in your own vocabulary and structure, learned from your existing reports. It does not score tests or calculate any results: those stay yours. Data stays in Europe, in France, on infrastructure certified for health data; the patient's name is pseudonymised before the AI and no audio file is kept. To go further, see what Delta is, Delta for neuropsychologists, our guide to AI in neuropsychology, choosing software for neuropsychologists and our other clinical document templates.

Sources

• Centre ressource de réhabilitation psychosociale, "Remédiation cognitive : outils", e-learning material (S.-L. Farhat, C. Duboc), accessed 01/11/2026 (in French).
• Tours University Hospital, CRT programme leaflet, La Chevalerie day unit (February 2021 edition, in French).
• Centre ressource de réhabilitation psychosociale, NEAR group presentation (in French).
• French Code of Ethics for Psychologists, 2021 version (articles 7, 8, 18, 23, in French).
• Psychiatric Times, "Guidelines for Developing a Cognitive Remediation Program for Patients With Schizophrenia", vol. 28 no. 3, March 2011 (unsigned).