Writing Therapy Notes Using The SBAR Framework
Writing therapy notes can be overwhelming. Between back-to-back sessions and client care, documentation piles up. That's where efficient techniques like the SBAR framework come in. It's a simple and powerful way to structure your therapy notes that saves you time while capturing vital information.
What is SBAR?
SBAR stands for Situation, Background, Assessment, and Recommendation. SBAR has become popular among therapists because helps you to:
Get the important details down quickly
Keep your notes organized and clear
Make sure nothing falls through the cracks
Communicate effectively with other providers
Let's look at each part of SBAR and how to use it in your therapy notes.
Situation: What's Happening Now?
This is where you capture what's going on with your client right now. Keep it simple and focus on:
Why they came in today
Any changes since last session
Current symptoms or concerns
Urgent issues that need attention
For example: "Client reports increased anxiety attacks this week (3-4 per day, up from 1-2). Having trouble sleeping and called in sick to work twice."
Background: What's the Context?
This covers the relevant history that helps explain the current situation. Include:
Important parts of their mental health history
Recent life changes
What's worked (or hasn't) in the past
Current medications or other treatments
Keep it focused on what matters for today's session. You don't need to repeat their entire history every time.
Assessment: What's Your Clinical Take?
This is where you share your professional view of what's going on. Focus on:
Your observations during the session
How they're progressing with treatment goals
Any risks or concerns
Patterns you're noticing
For example: "Client shows increasing ability to identify anxiety triggers but struggles with using coping skills in the moment. No current safety concerns. Work stress appears to be the main trigger for recent anxiety spike."
Recommendation: What's Next?
Here's where you outline the plan going forward:
What you did in session
Changes to the treatment plan
New coping strategies or homework
Next steps and follow-up plans
Real-World SBAR Examples
Depression Note Example
S: Client reports feeling "more down than usual" for the past week. Sleeping 10+ hours but still tired. Missing meals and avoiding phone calls from friends.
B: History of mild depression, usually manages well with exercise and social support. Recent breakup three weeks ago.
A: Shows signs of moderate depressive episode triggered by relationship loss. Good insight but struggling with basic self-care. No current safety concerns.
R:
Introduced basic behavioral activation plan
Set small daily goals for eating and movement
Scheduled check-in call between sessions
Next appointment set for Tuesday at 2pm
Anxiety Note Example
S: Client arrived 10 minutes early, visibly shaking. Reports panic attack during morning meeting at work. Says, "I can't keep doing this, I'm going to lose my job."
B: Started therapy 2 months ago for work-related anxiety. First panic attack was 3 months ago. Taking Zoloft for 6 weeks, prescribed by PCP.
A: Anxiety symptoms intensifying despite medication. Good motivation for treatment but overwhelmed by symptoms. Has strong support from spouse and manager at work.
R:
Practiced grounding techniques in session
Created a crisis plan for workplace panic attacks
Will coordinate with PCP about medication response
Weekly sessions to continue
Crisis Note Example
S: Client called crisis line reporting suicidal thoughts with plan. States "I can't take it anymore" after job loss yesterday.
B: History of depression and one previous suicide attempt 2 years ago. Recently stopped seeing psychiatrist due to insurance change.
A: High risk due to specific plan, recent loss, and history. Shows willingness to accept help and has supportive family nearby.
R:
Completed safety assessment
Created crisis safety plan with client and sister
Arranged emergency psychiatric evaluation
Follow-up session scheduled after evaluation
Best Practices for SBAR Documentation
Whether you're writing notes manually or using AI help, here are some tips for effective SBAR notes:
Keep it Clear:
Use simple language
Stick to relevant information
Include direct quotes when helpful
Focus on observable facts
Stay Compliant:
Include all required elements for insurance
Maintain appropriate confidentiality
Document risk assessments clearly
Note any coordination with other providers
Common Challenges with SBAR (And How to Solve Them)
Getting stuck with your SBAR notes? Here are common challenges and their solutions:
Notes Take Too Long
Use templates for common situations
Write notes right after sessions while fresh
Try AI tools like Supanote to automate the process
Focus on key information, not every detail
Unsure What to Include
Ask yourself: "What would another provider need to know?"
Stick to clinical observations
Include changes since last session
Document any risks or safety concerns
Complex Cases
Break information into smaller chunks
Focus on current priorities
Note patterns or any significant improvement across sessions
Update treatment plans as needed
Using AI to Save Time with Notes
Documentation can eat up hours of your week. This is where AI tools like Supanote come in. They can help you create detailed notes in minutes instead of hours.
How AI Note-Taking Works
Think of Supanote as having a super-efficient assistant who:
Listens to your sessions
Organizes information into your desired formats
Creates notes for your review
Ensures nothing important gets missed
With Supanote, you can:
Record your session directly or upload a recording
Review and make any needed changes
Copy to your EHR system
Real Time-Saving Benefits
Mental health professionals using AI for notes report:
Cutting documentation time from 30 minutes to less than 5 minutes
Getting notes done right after sessions instead of playing catch-up
More time to focus on client care
Better work-life balance
Seamless Setup :
Sign up for Supanote (takes less than 2 minutes)
Choose your preferred note format
Start recording or upload your session
Get your SBAR note drafted automatically
Key Features:
HIPAA-compliant security
Multiple note formats (SOAP, DAP)
Easy editing and customization
Direct EHR integration
FAQs About SBAR Notes
Q: How long should an SBAR note be?
A: Typically 250-400 words. Focus on quality over quantity for effective communication in a healthcare setting.
Q: Can I use SBAR form for all types of sessions?
A: Yes! SBAR works for individual, group, couples, and crisis sessions.
Q: Why is the SBAR tool preferred in health care documentation?
A: SBAR provides an approach to organizing notes for effective communication, patient safety, and collaboration among healthcare providers.
Q: What types of critical information should be included in an SBAR note?
A: SBAR notes should include key clinical observations, changes in the patient’s condition, urgent risks, and actionable next steps to ensure nothing vital is overlooked.
Q: What if I forget something important?
A: AI tools like Supanote help catch details you might miss. Plus, you can always update notes before signing.
Q: Is SBAR accepted by insurance companies?
A: Yes, SBAR communication technique meets documentation requirements when properly formatted.
Ease Your Clinical Workload Today
SBAR notes don't have to be complicated or time-consuming. With the right approach and tools, you can create clear, professional documentation that serves you and your clients well. Whether you're writing notes manually or using AI assistance, the SBAR framework helps ensure nothing important gets missed.
Ready to streamline your documentation process? Try Supanote for free today and see how much time you can save on your notes.