6 reasons your therapy notes take too long (and what you can do about it)

Documentation burden is one of the most consistently reported contributors to clinician burnout in healthcare. Research examining EHR use in mental health has found that EHRs often disrupt the very workflows therapists rely on, and that the problem is partly structural, partly behavioral, and partly psychological.

Most articles on this topic flatten that complexity into a list of productivity tips. This one tries not to do that. Some of what slows you down is genuinely outside your control. Some of it isn’t. You deserve to know which is which.

1. Your EHR wasn’t built for the kind of thinking therapy requires

Most EHR systems were designed around a structured medical model: checkboxes, coded diagnoses, and discrete data points. Therapy documentation is different: it’s narrative, relational, and contextual.

A 2022 scoping review in the Journal of Medical Internet Research found that EHRs often create friction in mental health settings because they weren’t built for narrative documentation. The same review found that clinicians sometimes watered down sensitive clinical content or kept shadow records because the EHR structure couldn’t accommodate it. A 2025 scoping review found that poorly designed interfaces led to excessive screen navigation, duplicated entry, and workarounds that increased both time and error risk.

What you can do 

This advice splits depending on whether you control your EHR setup or not.

If you have some control, audit it. Question every required field: does it serve a clinical or billing function? Build templates that pre-populate structural elements (date, session type, duration, CPT code) so you’re only writing clinical content from scratch. And if your EHR remains a hindrance, it’s time to switch to a better one.

If you’re in a group practice without meaningful control, individual productivity tips mostly miss the point. Build an organizational case for change instead. Document specific examples where the system forces duplicated entry, doesn’t support clinical templates, or pushes clinicians to keep records outside the official system.

2. You’re writing notes too long after the session

The longer you wait, the more you reconstruct rather than document. Reconstruction is slower, less accurate, and tends to produce notes that are either vague or padded. Medicare and Medicaid require progress notes within 24 to 48 hours, though enforcement is inconsistent. Same-day documentation is the practice most consistent with both accuracy and efficiency.

What you can do

Treat your note as part of the session. Build 10 to 15 minutes into your schedule after each client. Don’t book back-to-back without that buffer. If back-to-back sessions are unavoidable, jot a few words immediately after each one: the intervention, the client’s response, what to carry forward. Writing from a five-word reminder is dramatically faster than reconstructing a session from nothing.

You can also use an AI scribe like TheraNest’s AI Session Assistant. It creates a draft summary you can edit and review later, so it’s much faster.

3. You don’t have a locked-in note format

Without a committed structure, you’re making micro-decisions about organization every time you sit down to write. That compounds across a full caseload and produces notes that are inconsistent over time. They’re harder to use clinically and harder to defend if they’re audited.

Common formats in mental health settings include SOAP, DAP, and BIRP. SOAP works well in integrated or medical settings. DAP is efficient for outpatient individual therapy. BIRP is popular in community mental health because it links observable behavior to intervention and outcome, which helps demonstrate medical necessity to payers. None is inherently better. A format you use every session without deliberating is faster than the “right” format you’re still figuring out.

What you can do

Choose one format and commit to it for 90 days. Build a template in your EHR that prompts each section. For clinical content that repeats across similar sessions, like common interventions, standard risk screening language, create a phrase bank you can pull from rather than retyping each time. This is different from copying notes wholesale, which is both clinically inaccurate and a compliance risk. A phrase bank captures your standard language once and lets you adapt it to the specific session.

4. Your notes are longer than they need to be 

Fear is one of the least-discussed drivers of documentation time. The fear of an audit, a licensing board complaint, or a legal subpoena can push clinicians toward notes that try to anticipate every possible critique and end up far longer than the clinical or billing record requires.

Writing defensively means including details that aren’t clinically necessary, hedging language that obscures rather than clarifies, and documenting what didn’t happen as much as what did. The resulting note takes longer to write, is harder to read, and doesn’t meaningfully reduce legal risk. The APA’s Record Keeping Guidelines are explicitly aspirational rather than mandatory, based primarily on professional consensus rather than empirical research. You’re likely holding yourself to a standard that isn’t codified anywhere.

What payers and auditors are looking for: evidence the session occurred, the clinical service delivered, that the service was medically necessary, and a plan for next steps. A well-organized 200-word note that answers those questions clearly is more defensible than an 800-word narrative that buries the relevant information.

What you can do

Set a word target. A compliant, audit-defensible progress note for a standard outpatient session can usually be achieved in 150 to 400 words.

5. You’re not clear on what payers actually require

Payer requirements for mental health documentation are not uniform, and confusion about what’s actually required drives both over-documentation and unnecessary anxiety. A 2024 AHRQ technical brief identified billing and insurance-related tasks as a consistently significant contributor to clinician time in the EHR.

What you can do

Get the actual documentation requirements from your specific payers in writing. Most commercial payers publish provider manuals that specify what a note must contain to be billable and medically necessary.

For Medicare and Medicaid, CMS documentation requirements are publicly available. The core elements that appear consistently across payers are: date and duration, diagnosis consistent with treatment, description of the service and the client’s response, and a plan for future sessions. If your note contains all of that clearly, you’ve met the fundamental standard.

6. You received little formal training in efficient documentation

Most graduate programs cover what to document but give little attention to how to document it without spending three hours a night on notes. A 2021 scoping review in the Journal of the American Medical Informatics Association found that training on documentation efficiency is inconsistent across healthcare settings. Many therapists learned by watching supervisors and trial-and-error, carrying those habits (including inefficient ones) throughout their careers.

What you can do

Seek out continuing education on mental health documentation specifically. Professional associations, state licensing boards, and independent clinical educators offer courses that go beyond EHR onboarding.

Consider asking a trusted colleague or supervisor to review a month of your notes against a documentation audit tool. An external read often surfaces both over-documentation and under-documentation you’ve stopped noticing.

Can AI scribes help?

Increasingly, yes, though with real limitations worth understanding before you invest time or money.

AI documentation tools (sometimes called ambient scribes or AI scribes) listen to a session (with client consent) and generate a structured draft. A 2024 survey study published in JAMA Network Open found that clinicians using ambient documentation technology reported meaningful reductions in documentation burden and burnout.

Separate research suggests AI-assisted drafting can significantly reduce per-session documentation time, though estimates vary and most studies lack long-term follow-up.

AI scribes handle the structural scaffolding quickly, reduce the blank-page problem, and can be especially useful for clinicians who struggle with the transition from session to documentation.

But AI scribes won’t fix a bad EHR workflow, a misunderstanding of payer requirements, or inconsistent documentation habits. And because you remain clinically and legally responsible for every note, editing for accuracy isn’t optional, so the time savings depend heavily on how well the draft reflects what actually happened.

A few things to know before you start: most tools require client consent for session recording, which is a conversation to have proactively. Some clients will decline, and that’s a clinical consideration, not just a logistics one. Data privacy and HIPAA compliance vary by product, so review the vendor’s business associate agreement carefully before using any AI scribe with client sessions. If you’re exploring options, pilot one with a subset of consenting clients and track whether the time savings are real before committing.

A note on session modality

If you do significant couples, family, or group work, your documentation is genuinely harder. Standard formats like SOAP and DAP were largely designed for individual therapy. A family session with three participants and competing dynamics doesn’t reduce neatly to a single “Data” section. If modality complexity is a consistent time drain, check whether your EHR has modality-specific templates and raise it with your clinical director. It’s likely others in your practice have the same problem and no one has addressed it.

What this comes down to

Some of what slows your documentation down lives in your organization’s infrastructure, your EHR’s design, your payers’ requirements, or the training gaps your graduate program left. You didn’t create those constraints and can’t resolve them alone.

But the parts you can address, like when you write your notes, how long they are, what format you use, whether you actually know what your payers require, are worth examining honestly. The cumulative time cost of inefficient documentation across a full caseload competes directly with the energy you bring to your clients and to your life outside of work.

Efficient documentation isn’t about cutting corners. It’s about knowing what each note is for and writing it clearly enough to do that job, and not much more.

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