FieldNoteReference

Clinical documentation

The session ends. The note still has to get written, and it has to say what happened in words a reviewer accepts.

These guides give you formats, phrases and word banks to keep beside you while you write.

For therapists, social workers, counselors and MSW students.

12 live guides. Prices are in US dollars and the Etsy listing is the final word on price.

Not sure which one? Take the one-minute quiz.

Where to start

Toolkit

All eleven single guides in one bookmarked PDF, with a START-HERE guide and two annotated notes.

Complete Clinical Documentation Toolkit

56 pages. $19.

Eleven progress note guides in one download: note formats, S and O language, risk, assessment, plan, interventions, response, word bank and change language.

For clinicians and students in social work, counseling and marriage and family therapy who want the whole set.

What is inside
  • All eleven single guides, merged into one bookmarked PDF in each size.
  • The same guides as individual PDFs in two zip files, one for Letter and one for A4.
  • A START-HERE guide with a quick start, a contents table and two full fictional notes annotated line by line.

Single guides

One guide for one part of the note: formats, S and O language, risk, assessment, plan, interventions and word choice.

SOAP, DAP, BIRP, GIRP Note Formats at a Glance + Abbreviations

7 pages. $5.

SOAP, DAP, BIRP and GIRP note formats side by side, with the abbreviations that fit in them and two full notes annotated line by line.

For clinicians and students in social work, counseling and marriage and family therapy who write in more than one note format.

What is inside
  • The four note formats compared on one page, so you can see where each part of a note goes.
  • A reference table of abbreviations used in progress notes.
  • Two full fictional notes annotated line by line, so you can check your own notes against them.

Subjective (S) Phrase Guide

3 pages. $6.

Phrase guide for the S section of a progress note: which reporting verbs to use and avoid, when to quote the client, and 14 sentence stems.

For clinicians and students in social work, counseling and marriage and family therapy who write the Subjective section.

What is inside
  • Reporting verbs sorted into neutral wording and wording to avoid, for example "complained" becomes "expressed".
  • A guide to when to quote the client and when to paraphrase.
  • Ways to name other sources, such as family, staff or records.
  • 14 sentence stems that name the source of every statement.
  • A short fictional "See it in a note" example.

Mental Status Exam & Objective Language Guide

4 pages. $5.

Observable wording for the O section of a progress note: mood and affect, a descriptor bank for every mental status exam domain, and a quick template.

For clinicians and students in social work, counseling and marriage and family therapy who write the Objective section or a mental status exam.

What is inside
  • Wording options for mood and affect that describe what you observed.
  • A descriptor bank for every mental status exam domain, from speech and thought process to judgment.
  • A quick template for a case management note.
  • A short fictional "See it in a note" example.

Risk & Safety Documentation Phrase Guide

3 pages. $6.

Phrase guide for documenting risk and safety in a note: what you asked, what the client said, your judgment, what you did and who you consulted.

For clinicians and students in social work, counseling and marriage and family therapy who document risk screening and safety planning.

What is inside
  • The elements of a risk note, each with example wording: screening done, access to means, risk judgment, actions taken.
  • Sentence stems that record the question you asked along with the answer.
  • Wording for consultation and follow-up.
  • A short fictional "See it in a note" example.

Biopsychosocial Assessment Language Guide

3 pages. $6.

Thirteen biopsychosocial-spiritual domains, what to cover in each, example phrasing, and how to connect the domains in the Assessment.

For clinicians and students in social work, counseling and marriage and family therapy who write intake or biopsychosocial assessments.

What is inside
  • A table of thirteen domains, from housing and environment to spiritual and meaning to strengths and resources.
  • What to cover in each domain, with example phrasing.
  • Guidance on connecting domains in the Assessment instead of listing them.
  • A short fictional "See it in a note" example.

Assessment & Plan Writing Guide

4 pages. $6.

Guide to the A and P sections of a progress note: a three-part assessment, hedged interpretive language, progress wording, continued need and a plan checklist.

For clinicians and students in social work, counseling and marriage and family therapy who want stronger Assessment and Plan sections.

What is inside
  • A three-part structure for the Assessment section.
  • Hedged wording for impressions, so interpretation reads as interpretation.
  • Progress and functioning descriptors, from moving forward to holding to mixed.
  • Wording for continued need, and a plan checklist someone covering for you could follow.
  • Sentence stems and a short fictional "See it in a note" example.

Interventions by Modality Phrase Bank

5 pages. $6.

Intervention wording sorted by modality: case management, MI, CBT, DBT, SFBT, trauma-informed care, crisis work and family work.

For clinicians and students in social work, counseling and marriage and family therapy who document interventions.

What is inside
  • Phrases for what you did and what it was for, grouped by modality.
  • Case management and resource linkage wording, for example a warm handoff or an advocacy contact.
  • Wording for crisis work, trauma-informed care and family work.
  • A note to document only the interventions you delivered within your training.
  • A short fictional "See it in a note" example.

Client Response & Progress Language

3 pages. $4.

How the client engaged and what changed: response language by engagement level, sentence stems and progress descriptors.

For clinicians and students in social work, counseling and marriage and family therapy who record client response and progress.

What is inside
  • Response wording by engagement level: engaged, partial and declined.
  • Sentence stems for recording how a client responded to an intervention.
  • Progress descriptors for moving forward, holding and mixed.
  • A short fictional "See it in a note" example.

Informal-to-Clinical Swap List

3 pages. $4.

Informal-to-Clinical Swap List: 20 swaps from everyday note words to professional documentation language, each with its reason.

For clinicians and students in social work, counseling and marriage and family therapy who draft notes in everyday language.

What is inside
  • 20 swaps in a three-column table: instead of, write, why. For example, "refused" becomes "declined [what was offered]; client stated ___".
  • Swaps for labels that judge (manipulative, resistant, noncompliant, attention-seeking) with wording that records the behavior and the client's own words.
  • A test to run on every sentence: could the client read it and recognize the description as fair?
  • A short fictional "See it in a note" example: a quick draft beside the finished paragraph, with what to notice.

Clinical Documentation Word Bank

7 pages. $6.

Single words grouped by the job they do in a note: verbs, adjectives, nouns, qualifiers and connectors, alphabetized down each column.

For clinicians and students in social work, counseling and marriage and family therapy who want precise words at hand while writing.

What is inside
  • Word lists for verbs, adjectives, nouns, qualifiers and connectors.
  • Connectors grouped by purpose: show evidence, show cause, show contrast.
  • An intro on picking only the words your session supports.

Change & Interaction Language for Progress Notes

8 pages. $6.

Words for what happens between people: interactional patterns, attempted solutions and their effect, reframes and the client's response, first- and second-order change.

For marriage and family therapists, systemic clinicians and social workers who want words for interactional patterns.

What is inside
  • A vague-to-interactional swap table, for example "family is dysfunctional" becomes a description of the recurring pattern.
  • Sentence stems for recording a pattern, an attempted solution and its effect.
  • Wording for a reframe offered and how the client responded.
  • Wording for first-order and second-order change observed in session.
  • A short fictional "See it in a note" example.

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