Keeping Your Own Therapy Records: What to Note, What Not To

Therapy is one of the few medical relationships where the professional keeps detailed notes and the patient typically keeps none. This is often unhelpful — memory of what was discussed, what strategies were tried, what worked, fades within days. A brief personal record after each session preserves the arc of the work and makes the therapy itself more effective.

What to note after each session

• Date and duration.
• Main topics discussed (in your own words, not full transcript).
• Any insight or realisation.
• Specific strategies or homework assigned.
• Any medication discussion.
• Emotional state during and after.
• Next session focus if agreed.

What NOT to note

• Verbatim transcript — defeats the purpose of the confidential space.
• Judgements about the therapist that you wouldn't discuss with them.
• Diagnostic conclusions you haven't been given.
• Personal information about others discussed in session (privacy).

The specific value of the record

• Continuity between sessions — arrive with awareness of what was open.
• Tracking symptoms and their response to interventions.
• Recognising patterns over months.
• Reviewing progress at 3-6 month intervals.
• Sharing (selectively) with GP or psychiatrist coordinating care.
• Reference if changing therapists — starts new relationship faster.

The structure that works for most people

• Field: Date · Purpose: Chronology
• Field: Presenting mood (1-10) · Purpose: Trend
• Field: Topic covered · Purpose: Continuity
• Field: Key insight/realisation · Purpose: Progress marker
• Field: Homework · Purpose: Reminders
• Field: Follow-up needed · Purpose: Session prep

For medication management

• Which medicine, dose, since when.
• Side effects observed.
• Perceived effectiveness.
• Any dose change and its effect.
• Interactions with other medicines discussed.

The specific coordination with GP

Many mental health issues are managed jointly — therapist for talk therapy, psychiatrist for medication, GP for physical health. Sharing a brief summary (not full notes) with the GP helps coordination. What's useful: current diagnosis, current medications, any recent hospitalisation, current stability. What's not needed: session content, personal histories, specific techniques.

Privacy considerations

• Store in the private section of your health record if the app allows.
• Consider password-protecting mental health notes separately.
• Think carefully before sharing with family (even close family).
• Delete old notes you no longer need for continuity.
• For sensitive periods, physical notebook rather than digital may be preferred.

The trend view over 6 months

• Mood pattern — improving, stable, declining.
• Recurring themes.
• Sleep quality trend.
• Substance use if applicable.
• Social functioning.
• Work/study performance.
• Relationship quality.

A 6-month review of your own notes often reveals progress you hadn't noticed. The specific things you were struggling with in month 1 that no longer feature. This kind of visible progress is one of the strongest motivators for continued work.

References

• APA — psychotherapy guidelines
• PMC — patient participation in mental health records
• WHO — mental health self-management