Psychomotor therapy session notes: what to write down and template to download

The session note is the regular record of psychomotor follow-up. Brief but consistent, it ensures traceability, prepares progress reports, and secures patient care.

This page details what it should contain, its place in the patient file, and how it differs from the psychomotor assessment, with a ready-to-use template.

The session note in the patient file

The psychomotor therapist is a healthcare professional: they practice under medical prescription and maintain a file for each patient. The session note is part of the file's traceability: it documents the course and progress of the care, without having the formal value of a psychomotor assessment.

What a session note should contain

1. Date, duration, and session number. Chronological reference and continuity.
2. Targeted objectives. Linked to the therapeutic plan defined during the assessment.
3. Therapeutic media and activities. What was proposed (play, motor skills circuit, graphomotor skills, relaxation, etc.).
4. Clinical observations. Muscle tone, coordination, attention, emotional regulation, cooperation.
5. Progress. What is improving, stagnating, or regressing since the last session.
6. Adjustments. Modification of objectives, therapeutic media, or frequency.
7. Family / school link. Potential exchanges and advice.

A brief but regular note is better than a follow-up reconstructed from memory: it is what feeds the progress report.

Session note or psychomotor assessment?

• The psychomotor assessment is the formal written document, under prescription, which establishes the psychomotor profile and contributes to the medical diagnosis. It is sent to the doctor.
• The session note is the follow-up record, session after session, which documents the intervention and progress.

Retention and confidentiality

Health data is kept in an active database for 5 years from the last intervention, then archived (CNIL guidelines for the healthcare sector). The archiving period applicable to private practice should be confirmed based on your situation. Access remains restricted to authorised individuals.

Save time on your session notes

The bottleneck is repetition: one note per patient per session. Start with a fixed template, standardise your phrasing, and dictate the 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. HDS-certified hosting, GDPR compliant.

Frequently asked questions