Psychologist's session notes: framework, content, and template
Psychologist's session notes: their framework (professional confidentiality, non-transferable personal notes), what is useful to record in them, and a template to download.
Countries covered : France
Session notes are a psychologist's daily working tool, but they have a specific status. Knowing what they are (and are not), what to record in them, and how to protect them is essential.
This page details the framework, useful content, and offers a template to download.
The framework: personal notes for internal use
Practical consequence: clearly distinguish your session notes (for yourself, for continuity of care) from what you might formalise for a third party (a confirmation of ongoing care), which is subject to different rules.
What is useful to record
- Date and session number. A reference point for continuity.
- Themes addressed. The focus areas of the session.
- Useful clinical observations. What sheds light on the understanding and continuation of care.
- Hypotheses and lines of work. Leads for subsequent sessions.
- Framework elements. Appointments, absences, significant events in the care process.
The right balance: notes that are dated, concise, and focused on what is useful for continuity; the essential part remains the quality of the relationship, not the volume of writing.
Session notes template to download
Short and structured, ready to fill out after each session. Access the PDF by entering your email:
Confidentiality and retention
The GDPR applies to notes, whether they are on paper or on a digital tool: restricted access, data security. Keep them in a way that allows you to demonstrate compliance, and limit their content to what is necessary.
Save time on your notes
The main obstacle is consistency. Start with a fixed template, standardise your phrasing, and dictate your note right after the session.
This is what Delta does: you capture your observations through live note-taking or post-session dictation, and the tool generates a structured note based on your template, with longitudinal patient memory from one session to the next. Health Data Hosting (HDS), GDPR-compliant: your writings remain confidential and belong to you.
Frequently asked questions
Are a psychologist's session notes transferable?
No. They are personal notes for internal use; they are only disclosed to the courts upon requisition.
Is a psychologist required to keep notes?
There is no legal obligation to provide a report to the patient. However, concise notes remain useful for the continuity of care.
What should be included in a session note?
The date, themes addressed, useful clinical observations, hypotheses and lines of work, and framework elements, while remaining concise.
Are session notes and a confirmation of ongoing care the same thing?
No. Notes are for internal use; a confirmation of ongoing care is a written document given to the patient, subject to specific rules of caution.
Does the GDPR apply to paper notes?
Yes: the GDPR applies to data, whether on paper or digital; access must be restricted and secure.
Cut the time spent on your writing in half
Delta generates your notes and reports from your note-taking or dictation, in complete confidentiality (HDS / GDPR).
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