VHG guidance and standards for clinical notes for Cognitive Behavioural Therapy (CBT) clinical notes

1.   Purpose of this document

This document outlines VHG’s expectations and standards for clinical notes and provides guidance for network CBT therapists.

2.   Good practice guidance for CBT notes

The following guidance for CBT session notes is largely based upon the CTS-r framework. These areas may be more or less significant depending on where the client is in their therapy journey. This section briefly outlines VHG’s guidelines and standards for each of the following areas:

1.     Agenda Setting/Focus for session

1.     Formulation/Problem Statement

1.     Treatment plan

1.     Between Session Assignment Review

1.     Cognitive and Behavioural Targets for Intervention

1.     Change Mechanisms

1.     Goals and Progress Review

1.     Summary and Feedback

1.     Relapse Prevention

1.     Next Steps and Between Session Assignments

Risk assessment is a distinct area of record keeping and specific guidance on risk assessment is provided here: Risk & Safeguarding Knowledge Base (zohodesk.eu)

Examples of first session and follow-up risk assessments in session notes on MPB can be found here:

Clinical Support | CBT notes Knowledge Base (zohodesk.eu)

Agenda Setting/Focus for session

1.    Outline the collaborative agenda for the session, including topics the client wants to address and goals for the session. 

Formulation/Problem Statement

1.    A clearly documented (if early sessions) or reference to (in later sessions) a case formulation and how this is informing treatment plan. 

Treatment plan

1.    Clear how this session fits with broader treatment plan and goals for therapy.

Between Session Assignment Review

1.   Evaluate the completion and effectiveness of homework assignments from previous sessions.
   
2.   Discuss the client's experiences and insights gained.

Cognitive and Behavioural Targets for Intervention

1.  Identify specific cognitive distortions or negative thought patterns discussed during the session. and/or
   
2. Document behavioural targets or goals established with the client. 

Change Mechanism

1. Document cognitive strategies employed. 
   
2. Belief ratings obtained and reviewed
   
3. Changes in cognition documented
   
4. Changes in relationship to cognitive experience detailed (i.e. metacognition)
   
5. Linked to facilitating lasting behavioural change
   
6. Homework set in relation to cognitive intervention reported.
   
7. Document behavioural strategies and interventions when used and implemented during the session including third wave strategies (e.g. values work, mindfulness, compassionate other
   
8.  Include any homework assignments or action plans given to the client. 

Goals and Progress Review

1. Use rating scales alongside subjective assessments to measure the client's progress and changes in symptoms.
   
2. Note any improvements or challenges faced by the client.
   
3. Goals set (in early sessions) or reviewed (in later sessions). When goals are being set, where possible they should be SMART. 

Summary and Feedback

1. Summarize key points discussed during the session.
   
2. Document any feedback received/obtained. 

Relapse Prevention

1. Towards the end of therapy, evidence of relapse prevention planning/therapy blueprint and managing ending where appropriate. 

Next Steps and Between Session Assignments

1. Outline the action plan for the client until the next session.
   
2. Where appropriate, consideration to be given to the plan for next session.

3.   Questions?

Any questions about this guidance or any other aspect of clinical record keeping at VHG can be sent to network.clinical@vitahealthgroup.zohodesk.eu