Notes that support the code and the kid.

Progress notes vs psychotherapy notes

Two different things share the word "notes." The progress note is part of the medical record: it documents the session, supports the CPT code you bill, and can be requested by the payer, by a parent (with limits), or by a court. Psychotherapy notes, sometimes called process notes, are your private analysis, kept separately from the record; HIPAA gives them extra protection and payers cannot demand them. Write the progress note for the record and keep your reflections out of it.

DAP and SOAP, with a child in the room

Both formats organize the same facts.

DAP is Data, Assessment, Plan. For a nine-year-old seen with a parent for the last ten minutes:

• Data: who attended and where they joined from; the parent's report of the week; what the child said and did in session (play observations, mood, engagement); the interventions you used and the child's response.
• Assessment: how this connects to the treatment plan and diagnosis; risk, if any; progress.
• Plan: the next session's focus, homework for the family, any coordination.

SOAP is Subjective, Objective, Assessment, Plan; the split between the parent's and child's account (subjective) and your observations (objective) can be useful with children, where the two often disagree.

Either format works. Payers do not care which; they care that the note contains what supports the code.

What a note must contain to support the code

For every timed psychotherapy code (90832, 90834, 90837) and the family codes (90846, 90847):

1. Start and stop time, or total face-to-face minutes.
2. Who attended (child, which parent, siblings) and, for telehealth, where each joined from.
3. Modality (video, or audio-only and why).
4. Presenting concern and interval history.
5. Interventions and the child's response.
6. Progress against the treatment plan goals.
7. Risk, when relevant.
8. Plan and homework.
9. Signature and date, ideally the same day.

Missing time is the most common reason a payer downcodes or denies. See the CPT codes guide.

Treatment plans for children

A treatment plan is written with the parent and, at an age-appropriate level, with the child. It should hold up to two questions: does the parent recognize the goal as the reason they came, and could a nine-year-old say what they are working on? Good plans have:

• A problem statement in the family's words.
• Two to four goals, each with measurable objectives ("fewer than two school refusals a week for four weeks", "SCARED total under 25").
• The interventions you will use and how often sessions happen.
• Who is involved (parent sessions, school coordination, prescriber).
• A review date, usually every 90 days, and what changed at review.

Payers ask for the plan on audit and expect the notes to reference it.

Measurement-based care, in plain terms

Measurement-based care means picking a validated scale for the age and the target, running it on a schedule, and using the result in the session. For children and teens the common ones are the PHQ-A (depression, 11 to 17), the SCARED (anxiety, 8 to 18, parent and child versions), the Vanderbilt (ADHD, parent and teacher), and the PSC-17 as a broad screen. Every two to four weeks is a workable cadence for anxiety and mood; before each medication visit for ADHD scales. The point is not the number; it is that you and the family see change, or the lack of it, and adjust.

AI-drafted notes: what good looks like

An AI draft should read like a note you would write on a good day: the facts of the session, in the format you use, with the time and participants filled in from the visit and the plan goals pulled from the record. It should not invent interventions you did not use, should not diagnose for you, and should mark anything it inferred. You review every line, edit what is wrong, and sign. The signature is yours; the draft is a tool. Families should be told, in the consent, that AI assists with documentation and how recordings or transcripts are handled.

Signing and timeliness

Payers expect the note within 24 to 72 hours of the session; many group contracts say 24. On Emora the signed note is what triggers your pay per completed session, so same-day signing is both good practice and good sense.