ERP session note template for OCD (exposure and response prevention)

An exposure and response prevention (ERP) session note is the written record of a CBT session for obsessive-compulsive disorder (OCD). It sets out the exposure exercise done, anxiety before, at peak and after, the rituals resisted or performed, family accommodation and the task agreed for the week. It rests on the exposure hierarchy, the graded list of situations the client has chosen to face with you.

What this page adds to the general CBT note

The general structure of a CBT session (homework review, measures, agenda, functional analysis, interventions, task) is covered in our CBT session note template. We do not repeat it here. This page deals with what is specific to OCD: the exposure hierarchy, three-point anxiety ratings during the exercise, the difference between overt rituals, mental rituals and reassurance seeking, family accommodation, and monitoring with a clinician-administered measure.

The hierarchy comes from your formulation. If you use the 5Ps case formulation, the perpetuating factors (avoidance, rituals, reassurance) give you the items directly. Goals belong in the treatment plan, and every note should link back to it.

What the guidelines say

In the UK, NICE guideline CG31 (last reviewed 11 July 2024, update in progress) recommends offering adults low-intensity psychological treatments including ERP, up to 10 therapist hours per patient, when functional impairment is mild and/or the patient prefers a low-intensity approach (1.5.1.1). For adults living with family or carers, involving a family member or carer as a co-therapist in ERP should be considered where this is appropriate and acceptable to those involved (1.5.2.4). Where family members have become involved in compulsions, avoidance or reassurance seeking, treatment plans should help them reduce that involvement in a sensitive and supportive manner (1.5.2.9). These points are a good reason to document the family, not only the client.

In France, the HAS guide on severe anxiety disorders (June 2007) describes CBT, based on exposure with response prevention, as the treatment of choice for OCD, says that in most cases it involves at least 25 sessions of about 45 minutes, and states that OCD can be assessed with the Yale-Brown obsessive-compulsive scale. For children and adolescents with moderate to severe OCD, it says CBT must involve the family or carers. In Ireland, Belgium and Switzerland we found no national guidance specific to ERP documentation; general record keeping and confidentiality rules apply, and the template below works the same way.

Template 1: exposure hierarchy to copy

One line per item, from least to most anxiety-provoking. Build it with the client, in session, from concrete situations in their life.

• Header: client (initials or reference), date created, date last updated, OCD theme (contamination, checking, symmetry, intrusive thoughts…), scale used and its anchors (for example 0 = no anxiety, 100 = the worst anxiety this client can imagine).
• Item number: a stable number, even if the order changes later.
• Exposure situation: precise enough to repeat (place, object, duration, what the client touches, looks at or imagines).
• Type: in vivo, imaginal or interoceptive.
• Ritual or avoidance targeted: what the client agrees not to do (washing, checking, asking for reassurance, mental neutralising).
• Expected anxiety: the client's rating when the item is created.
• Status: to do, in progress, done in session, done alone, mastered.
• Latest rating: peak anxiety at the last exposure, with the date.

Three practical rules: keep between eight and fifteen items so the list stays readable, date any item added along the way, and never delete a mastered item, change its status. The hierarchy then shows the progress made on its own.

Template 2: ERP session note to copy

• Header: date, session number, length, who attended (client alone, with a relative), setting (clinic, home, video).
• Homework review: items done alone, how often, client ratings, difficulties, rituals done anyway.
• Events of the week: new trigger, new ritual, any change in medication reported by the client.
• Today's exercise: item number, exact instruction, type, actual duration, place.
• Prediction: what the client feared would happen, in their words, and what happened.
• Anxiety: before, peak, after (end of exercise), on the hierarchy scale.
• Response prevention: rituals resisted, rituals performed (fully or partly), mental rituals identified, reassurance seeking.
• Family accommodation: what relatives still do for the OCD, what was agreed.
• Clinician's analysis: what the exercise taught, main obstacle, decision on the hierarchy (stay, move up, add a variant).
• Between-session tasks: item, frequency, duration, what to note, what the client will not do.
• Clinician-administered measure: if administered, its name, version, date and the total score you calculated.

Rituals performed, resisted and mental

Keep three things apart. Overt rituals (washing, checking, ordering), mental rituals (counting, praying, repeating a phrase, reviewing a scene) and reassurance seeking (asking a relative, searching online, asking you in session). A mental ritual written up as "no rituals" skews everything that follows. Also note partial or delayed rituals (washing two hours later), which often explain an exercise that is not moving.

Family accommodation

Describe behaviour, not judgement: "partner washes his laundry separately", "mother answers questions about cleanliness several times a day, according to the client". Note who is involved, what was proposed and how each person responded. When a relative attends part of the session, say so in the header and note what was explained to them.

Monitoring with a clinician-administered measure

The Y-BOCS, or the CY-BOCS for children, is administered at points you set in the plan: at the start, at regular intervals and at the end. We suggest using the official version of the measure and not copying its items into the note: the name, version, date and total score you calculated are enough. Keep the scoring sheet in the file. Between administrations, the hierarchy and the anxiety ratings track change session by session.

Fictional example over two sessions

Fictional example. Camille, 31, seeks help for contamination OCD with prolonged hand washing. She lives with her partner, Julien. Scale chosen: 0 to 100 (0 = no anxiety, 100 = the worst anxiety she can imagine).

Camille's hierarchy (updated at session 7)

• Item 1: touch the front door handle and not wash hands for an hour. Expected 30. Mastered (session 4).
• Item 2: touch the stair rail in her building, then her phone. Expected 40. Done alone.
• Item 3: put her bag on the clinic floor, pick it up onto her lap and touch her face. Expected 55. Done in session (session 6).
• Item 4: touch the kitchen bin, then cook a meal without washing. Expected 65. To do.
• Item 5: use the clinic toilet and wash hands once, for twenty seconds. Expected 75. In progress (session 7).
• Item 6: hold the underground rail, then eat a piece of fruit without washing. Expected 85. To do.
• Item 7: wash her laundry with Julien's without rewashing. Expected 90. Added at session 7.

Session 6

• Header: session 6, 60 minutes, Camille alone, at the clinic.
• Homework review: item 1 done daily, peak between 20 and 30. Item 2 tried twice, stopped after ten minutes with washing.
• Today's exercise: item 3, 40 minutes, in vivo.
• Prediction: "I'll break out in spots and won't be able to think of anything else all day." At the end: no spots, the thought still there but weaker.
• Anxiety: before 50, peak 70, after 35.
• Response prevention: no washing during the session. Rubbed her hands on her trousers once (partial ritual, identified with her). Mental ritual: repeats "it's clean, it's clean"; agreed she will note it in her diary.
• Family accommodation: Julien answers "is this clean?" several times a day, according to Camille. Invitation for him to join next session, accepted.
• Analysis: anxiety fell without washing, which contradicts the prediction. Item 2 stopped at home because of immediate washing after contact. Decision: return to item 2 before moving up.
• Tasks: item 2 once a day, 30 minutes without washing, rate before, peak and after. Count reassurance requests to Julien.

Session 7

• Header: session 7, 60 minutes, Camille, with Julien for the last 20 minutes, at the clinic.
• Homework review: item 2 done five days out of seven, peak down from 60 to 40 by the end of the week. Four to six reassurance requests a day according to her diary. Delayed washing after item 3 held for an hour, then a long wash.
• Today's exercise: item 5, 35 minutes, in vivo.
• Prediction: "I won't be able to stop at one wash." Outcome: one wash, longer than planned.
• Anxiety: before 70, peak 80, after 50.
• Response prevention: single wash held, 45 seconds instead of 20 (partial ritual, noted). One reassurance request to the clinician, named and not answered on substance, as agreed.
• Family accommodation: Julien has washed his laundry separately for a year and answers every cleanliness question. Explained the role of reassurance in keeping OCD going. Three-way agreement: Julien replies "we agreed I don't answer that one" and suggests another activity. Separate laundry becomes item 7.
• Analysis: good progress on item 2. Item 5 needs more work; washing time is the target. The family is now part of the plan.
• Tasks: item 2 three times this week, item 5 next session. Julien and Camille each note reassurance requests and the reply given.
• Clinician-administered measure: Y-BOCS administered at session 1, total score entered in the initial assessment. Next administration planned at session 10 as per the plan.

Common mistakes

• A single anxiety rating: without before, peak and after, you cannot see what happened during the exercise.
• Switching scales mid-treatment: a 7 out of 10 and a 70 out of 100 do not always mean the same to the client. Put the scale and its anchors in the hierarchy.
• Writing "no rituals" without asking about mental, partial or delayed rituals.
• Leaving out reassurance sought from you: it is a maintaining behaviour and is noted like the others.
• A frozen hierarchy: items never updated, new rituals never added, mastered items deleted.
• A vague task: "do more exposure" cannot be checked. Note the item, frequency, duration and what the client will not do.
• Ignoring the family: with no trace of accommodation, it is hard to see later why gains in session do not carry over at home.
• Copying items from a standardised measure into the note: name, version, date and total score are enough.

Why Delta suits this work

Delta is a clinical assistant for mental health professionals, more than a scribe: it keeps the memory of each client, which matters in ERP where each session builds on the last. During the session, Delta transcribes what is said, or you dictate your observations afterwards. It produces the session report (short summary, detailed summary, topics for next session) taking your CBT approach into account, and updates the patient record with a summary of care and the goals being tracked.

In couple or family sessions, Delta tells the voices apart, which helps when documenting family accommodation. Delta does not calculate any score: you administer the Y-BOCS and enter the result yourself. Data is hosted in France with an HDS-certified provider, the client's name and identifying details are pseudonymised before AI processing, and no audio file is kept. For clinicians in the UK, Ireland, Belgium and Switzerland, data stays in Europe, in France, on infrastructure certified for health data. To compare tools, see our psychologist practice software guide, Delta for psychologists or what Delta is. All our templates are gathered in clinical document templates.

Sources

• NICE, Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG31), recommendations, last reviewed 11 July 2024
• HAS (France), long-term psychiatric conditions: severe anxiety disorders (ALD 23 guide), June 2007, in French
• Government of Ontario, support sheet on group exposure and response prevention treatment, in French