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Finished note
Example — generated by Notat from a sample visit
Presenting concern: Reports increased anxiety and disrupted sleep during a period of work-related stress. Denies thoughts of self-harm. Assessment: Anxiety symptoms affecting sleep and daily functioning; no immediate safety concern disclosed. Plan: Discussed coping strategies, sleep routine, and follow-up. Patient knows how to seek urgent support if safety concerns arise. Clinical documentation: Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.
FactsContext™
symptoms
Anxiety: Increased anxiety during work-related stress
Sleep: Disrupted sleep
denials of symptoms
Denies: Risk: Denies thoughts of self-harm
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
plan
Support: Coping strategies, sleep routine, and follow-up discussed
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
history of present illness
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
Template
Counselor Note Identifying Information: [Client name, age, gender, relevant background] Presenting Problem: [Brief statement of reason for visit or referral] [Duration and context of presenting issue] History: (hyphenated list) - [Relevant psychosocial history] - [Past psychiatric history] - [Medical history] - [Family history] - [Social history] - [Substance use history] Mental Status Examination: (hyphenated list) - [Appearance] - [Behavior] - [Mood] - [Affect] - [Speech] - [Thought process] - [Thought content] - [Perceptions] - [Cognition] - [Insight] - [Judgment] Interventions: (hyphenated list) - [Therapeutic techniques used] - [Client response to interventions] - [Skills or strategies discussed] - [Homework or assignments given] Assessment: (hyphenated list) - [Summary of client’s current status] - [Progress toward goals] - [Barriers or challenges identified] Plan: (hyphenated list) - [Goals for next session] - [Planned interventions] - [Referrals or resources provided] - [Follow up arrangements]
Shared by
SO
Sarah O’Connell
Mental Health Counselor, Ireland
How it works in Notat
Add this template to your library, record the visit as usual, and Notat drafts the note in this exact structure from the extracted clinical facts. You review, edit, and sign.
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