Speech and language therapy session notes: what to write down and template to download

Session notes are the most frequent and quickest written records in speech and language therapy practice. Properly maintained, they ensure the traceability of care, prepare for renewal assessments, and protect the practitioner in the event of an audit.

This page details what they should contain, their place in the patient file, how they differ from the assessment report, and offers a ready-to-use template.

Session notes in the patient file

Unlike the speech and language therapy assessment report (CRBO), which has a regulated structure, session notes do not have to follow detailed regulatory specifications. They are part of the traceability of the patient file, which is both an ethical and professional obligation: the file gathers and stores formalised, updated information for each patient under care.

What a session note should contain

1. Date, duration, and session number. Chronological reference and continuity of care.
2. Targeted objectives. Linked to the care plan defined during the assessment.
3. Activities and exercises proposed. What was done during the session.
4. Clinical observations. Reactions, successes, difficulties, fatigue levels, cooperation.
5. Observed progress. What is improving, stagnating, or regressing since the previous session.
6. Adjustments. Changes to objectives, frequency, or modalities.
7. Carryover and home practice. Instructions given to the patient or their family.

The goal is not to write at length, but to write useful and dated information: a brief but regular note is better than a report reconstructed from memory weeks later.

Session note or assessment report?

These are two distinct documents that should not be confused:

• The assessment report (CRBO) is the formal, structured document that establishes the speech and language therapy diagnosis, sets the objectives, and outlines the care plan. It determines billing codes and must be kept on file.
• The session note is the record of progress, session after session. It feeds into the patient file and prepares for the next assessment, but it does not have the same formal value as the CRBO.

In practice, regular and consistent session notes greatly facilitate the writing of the reassessment, which must objectively document progress.

Retention and confidentiality

Health data is kept in an active database for 5 years from the last intervention in the file, then archived rather than deleted (CNIL guidelines for the healthcare sector). The archiving period applicable to private practice should be confirmed based on your situation. Throughout this period, access must remain restricted to authorised individuals.

Save time on your session notes

The main obstacle is not difficulty, but repetition: one note per patient per session, sometimes fifteen times a day. The solution lies in three habits: starting from a fixed template, standardising recurring phrasing, and dictating the note right after the session, while observations are still fresh.

This is exactly 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 a longitudinal patient memory that reuses the patient history from one session to the next. HDS-certified hosting, GDPR-compliant.

Frequently asked questions