Documentation Anxiety: How to Write Ethical, Minimal, and Defensible Psychotherapy Notes in Ontario

For many early-career Registered Psychotherapists in Ontario, documentation is one of the most anxiety-provoking parts of practice.

You finish a session feeling grounded in the work, then open Jane or Owl and hesitate. Did I include enough? Did I include too much? What if the client asks to see this later? What if this is reviewed by the College of Registered Psychotherapists of Ontario or an insurer?

If this sounds familiar, you’re not alone. Documentation anxiety is extremely common early in practice — and, importantly, it is not a sign you’re doing something wrong. It usually means you care about ethical practice and professional accountability.

This article offers an Ontario-focused, evidence-informed approach to writing psychotherapy notes that are ethical, minimal, and defensible, without turning documentation into a second full-time job.

What psychotherapy notes are actually for

Progress notes are often misunderstood. They are not meant to be transcripts of sessions, personal journals, or a record of everything a client has ever disclosed.

In Ontario, psychotherapy notes serve a few core purposes:

• supporting continuity of care

• documenting clinical reasoning and decision-making

• addressing risk when clinically indicated

• demonstrating ethical and professional practice

• meeting regulatory and legal obligations under CRPO standards and PHIPA

Canadian medico-legal guidance is clear that clinical notes do not need to be exhaustive; they need to provide an adequate picture of the clinical situation and the clinician’s reasoning (Canadian Medical Protective Association [CMPA], 2021).

The “Minimal – Useful – Defensible” principle

A helpful way to reduce documentation anxiety is to use the Minimal – Useful – Defensible framework, which aligns well with both CRPO expectations and Canadian privacy law.

Minimal

Document only what is necessary for treatment, continuity, and risk management. The principle of collecting the minimum necessary information is embedded in Ontario privacy legislation and reinforced by professional standards.

Over-documentation can increase risk by introducing unnecessary detail, third-party information, or speculative language that does not meaningfully support care (CRPO, 2024).

Useful

Your notes should help someone else understand what is happening clinically — including future you.

Professional psychotherapy guidelines emphasize documenting the client’s presenting concerns, the interventions used, and indicators of progress or change (MDPAC, 2024). Research on routine outcome monitoring also shows that briefly tracking progress improves clinical decision-making and helps identify clients who may be “off track” (Monaci et al., 2025).

Defensible

A defensible note shows that you exercised reasonable clinical judgment. This is especially important when documenting risk, boundary decisions, changes in treatment, or referrals.

Importantly, defensibility is not about length. Clear documentation of why you acted as you did is more protective than pages of narrative detail (CMPA, 2021).

What belongs in a psychotherapy progress note (Ontario context)

At minimum, a psychotherapy note in Ontario should include:

• date, duration, and modality (in-person, virtual, phone)

• who was present

• presenting focus or therapeutic target

• brief description of interventions used

• client response or progress indicators

• plan and next steps

• risk assessment when clinically indicated

• documentation of consultation or supervision when relevant

CRPO’s Clinical Records Checklist emphasizes legibility, chronological order, and clarity, with the expectation that another clinician could reasonably understand the clinical picture from the record (CRPO, 2024).

What to leave out (and why)

Many early-career therapists over-document out of fear. In practice, this often creates more risk rather than less.

Generally, avoid including:

• excessive narrative detail

• speculation or unverified hypotheses

• unnecessary third-party information

• emotionally charged or judgmental language

• verbatim dialogue unless clinically essential

• personal reactions better suited for supervision

If a detail does not advance care, clarify reasoning, or address safety, it likely does not belong in the record.

This same principle applies outside progress notes as well. In our OntarioSupervision.ca post Ethically Navigating Client Requests for Letters in Ontario, we discuss how documentation should always serve a clear ethical or clinical purpose — not function as a defensive transcript.

How detailed is “just right”? A comparison

Too vague
“Discussed anxiety. Client stressed. Homework assigned.”

This provides no clinical context, no intervention detail, and no plan another clinician could follow.

Just right

• Presenting focus: client reported persistent worry related to starting a new job

• Assessment: GAD-7 decreased from 14 to 10; no suicidal ideation; protective factors include supportive partner

• Interventions: cognitive restructuring of catastrophic thoughts; diaphragmatic breathing practised in session

• Client response: engaged, reported mild relief and increased insight

• Plan: practise breathing daily; track worry episodes; follow up next session

Too much
A blow-by-blow account of the client’s day, verbatim dialogue, detailed bodily sensations, therapist commentary, and unrelated personal history.

The middle example is almost always the safest and most useful.

Reducing note bloat with better templates

Evidence from clinical documentation research shows that well-designed note templates significantly reduce length while preserving clarity. Studies examining redesigned progress-note templates found substantial reductions in note length without loss of clinically relevant information (Pisciotta et al., 2023).

For psychotherapy, structured formats such as DAP or SOAP work well and are consistent with Canadian psychotherapy guidance (MDPAC, 2024).

A simple structure might include:

Data – client report, therapist observations, outcome measures
Assessment – clinical formulation, progress, risk if relevant
Plan – interventions used, homework, referrals, next steps

Refining templates over time — particularly through feedback in clinical supervision — can dramatically reduce documentation stress and improve consistency.

Writing notes with the reader in mind

Research on client access to clinical notes shows that when clinicians assume notes may be read, they naturally shift toward clearer, more neutral language without abandoning clinical judgment (Meier-Diedrich et al., 2025).

In Ontario, clients have the right to request access to their records under PHIPA. Writing notes that are respectful, accurate, and free from unnecessary speculation protects both client dignity and professional standing (CRPO, n.d.).

Documenting risk without panic

Risk documentation is one area where slightly more detail is often appropriate — but structure matters.

When risk is present, notes should briefly document:

• what was assessed

• protective factors

• current level of risk

• actions taken (safety planning, referrals, consultation)

• follow-up plan

Canadian medico-legal guidance emphasizes documenting assessment and response rather than exhaustive narrative detail (CMPA, 2021).

Using supervision to build confidence

One of the most effective ways to reduce documentation anxiety is reviewing notes in clinical supervision. Supervisors can help calibrate what is “enough,” identify unnecessary detail, and strengthen documentation of clinical reasoning.

For registrants working toward independent practice, this process also supports alignment with CRPO supervision expectations. It demonstrates reflective practice, ethical awareness, and sound judgment — qualities the College values far more than lengthy notes.

A final self-check before you save

Before closing the chart, ask yourself:

• Would another clinician understand what happened and why?

• Does this respect the client’s dignity if they read it?

• Did I document risk or consultation if needed?

• Is this clear, concise, and purposeful?

If yes, you are likely right where you need to be.

Final thought

Documentation anxiety is not a sign of incompetence — it is often a sign of conscientious practice. By focusing on what is ethically required, clinically useful, and professionally defensible, you can write notes that support client care, protect your practice, and free up energy for the work that matters most.

References

Canadian Medical Protective Association. (2021). Documentation and record keeping: Good practices. https://www.cmpa-acpm.ca

College of Registered Psychotherapists of Ontario. (2024). Clinical records checklist. https://crpo.ca

College of Registered Psychotherapists of Ontario. (n.d.). Professional Practice Standard 5.1: Clinical records. https://crpo.ca

Meier-Diedrich, E., Blease, C., Heinze, M., Wördemann, J., & Schwarz, J. (2025). Changes in documentation after implementing open notes in mental health care: A mixed-methods study. Journal of Medical Internet Research, 27, e72667.

Medical Psychotherapy Association Canada. (2024). Guidelines for the practice of psychotherapy. https://www.mdpac.ca

Monaci, M., Javaher, S., & Barello, S. (2025). Open notes in mental health: A scoping review of stakeholder experiences and implications for clinical practice. Healthcare, 13(21), 2777.

Pisciotta, M., et al. (2023). Novel note templates to enhance signal and reduce noise in clinical documentation. JMIR Formative Research, 7, e41223.