AI and therapy notes
AI for therapy notes may help alleviate one of the most time-consuming tasks for therapists who seem to have endlessly busy schedules.
Summary
- AI tools like voice-to-text dictation, session summarizers, and auto-filled SOAP note templates help therapists streamline their workflow, allowing them to spend more time on clinical care and less on paperwork. Download our free notes templates.
- Beyond transcription, AI tools can identify key discussion points, track clinical patterns, and even make treatment plan suggestions—supporting evidence-based care while maintaining clinician oversight.
- Therapists must ensure their AI tools are HIPAA-compliant and uphold data security standards. Informed consent is especially important when using voice recordings or storing session data.
- TheraPlatform, an all-in-one EHR with built-in AI-powered notes can help you streamline documentation through smart text, voice dictation, and auto-generated telehealth notes. All documentation is HIPAA-compliant, securely stored, and never used to train third-party AI models.
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Documentation is a necessary part of maintaining records and complying with legal and billing requirements. But writing therapy notes in between back-to-back therapy appointments isn’t easy. Administrative burdens like this can feel draining to clinicians, and takes away valuable time spent using their clinical skills.
Fortunately, evolving technology and Artificial Intelligence (AI) is rapidly transforming healthcare and streamlining tasks such as writing therapy notes. Let’s take a look at how using AI for therapy notes can assist clinicians with documentation, exploring the benefits, tools available, ethical considerations, and practical tips for implementation.
Using AI for therapy notes
AI can help therapists automate therapy notes, enhancing their efficiency and accuracy. Using therapy notes AI may even improve the clinical value of your therapy notes.
Here are some of the key ways that AI is currently being used to automate therapy notes:
Voice-to-text dictation
Using voice-to-text AI for therapy notes can help therapists dictate their notes immediately following a session. Documenting while the details of a session are still fresh can allow for more accuracy compared to dictating manually at the end of a busy day.
Google Voice Typing is a stand-alone tool that transcribes spoken words into text. In addition to a high level of accuracy, these voice-to-text dictation tools allow for quick, natural reflections on the details of a session.
The downsides of using stand-alone tools are the cost and lack of integration with your EMR/EHR, which can lead to less efficient workflow. To eliminate the need for multiple tools, consider partnering with an all-in-one EHR like TheraPlatform.
AI-generated session summaries
Some AI tools can do more than simply transcribe, they can actually analyze audio from a session to generate a summarized version of the conversation.
Automated session summaries can be a game-changer for busy therapists. Therapists can participate in a more natural conversation during the appointment without having to worry about writing detailed notes at the same time when using AI for therapy notes to complete a session summary.
The automated session summary can be used to write the therapy note at the end of the session. It also helps therapists ensure they don’t miss details on clinically significant information, such as specific therapy strategies that were discussed.
However, this tool still requires clinicians to go over the summary to write a clinical note. An alternative to this issue is a tool like TheraPlatform that automatically transcribes recorded telehealth sessions and with a click of a button, generates HIPAA-compliant SOAP notes.
Automated SOAP note templates
AI for therapy notes can help auto-fill sections of SOAP (Subjective, Objective, Assessment, Plan) notes within structured documentation formats. Some platforms can use session transcripts and checkboxes to pre-populate fields of the note.
For example, AI can detect when a therapist is using a standardized rating scale or questionnaire, and automatically input these scores into the “Objective” section of the SOAP note.
When next steps and recommendations are discussed, AI tools can detect that this information should populate into the “Plan” section.
Therapists can review the SOAP notes for accuracy, refining and elaborating as needed. Automation of SOAP notes can cut down on documentation time while also enforcing consistency of notes.
Download My Free Therapy SOAP Notes Template
Smart suggestions for treatment plans
A therapist’s clinical judgement is irreplaceable. However, AI can offer valuable assistance in suggesting treatment plans that can be helpful in guiding clinicians.
AI can analyze session data, identify patterns, and consider the client’s diagnosis and history to make informed suggestions. This can help therapists tailor treatment plans to fit each individual client’s needs while also aligning with evidence-based practices.
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Best AI tools for automating notes
Therapists can use top tools like these to use AI for automating session notes:
AI-powered EHRs
Some Electronic Health Record (EHR) systems have AI features integrated directly into their note-taking functionality and include different formatting options.
EHR platforms such as TheraPlatform offer AI note solutions that turn text and audio inputs into clear, concise SOAP notes. Additionally, you can record and transcribe telehealth sessions and TheraPlatform’s AI will turn those recordings into polished clinical notes.
Note-taking apps
AI for therapy notes apps allow therapists to transcribe and summarize audio recordings. These applications may offer specific features that are tailored specifically to fit the needs of therapists.
Note-taking apps may have the ability to integrate with an existing EHR system or may be able to provide secure cloud storage of session notes.
When considering AI tools for automating notes, therapists should consider their specific needs, the security and compliance measures offered, and their budget.
Free Resources for Therapists
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Ethical and compliance considerations
Adherence to ethical and legal requirements is critical when integrating AI into session documentation and note taking.
HIPAA-compliant AI for therapy notes
Maintaining HIPAA compliance is essential. Therapists must ensure that any AI tool being used to complete therapy notes is fully compliant with HIPAA requirements.
The AI for therapy notes tool must have robust security measures that include encryption, data breach protocols, and access controls. Protected Health Information (PHI) must also remain confidential.
Data security
Therapists should have a clear understanding of how the AI tools they use are storing, processing, and utilizing client data.
Ensure that the AI tool has clear data policies and strong security practices. Tools that may share or use client data for other purposes beyond note-taking and do not offer anonymization or consent should be avoided.
Transparency with clients
Therapists should consider being transparent with clients about the use of AI in administrative tasks such as treatment note documentation. If voice recording is involved, therapists must obtain informed consent from the client. TheraPlatform’s EHR for example, has built-in, ready to use consent forms (including one for AI) that you can modify to meet your needs and electronically send to clients to request their e-signatures.
Tips for using AI therapy notes
Consider these factors when using AI in treatment sessions:
- Use templates. A customizable template for note taking can help you complete session notes efficiently while still entering clinical information first hand.
- Start small. Try out AI therapy notes tools like voice-to-text dictation to see how they affect and potentially improve your workflow.
- Review and edit. Always review AI-generated content to ensure accuracy. Edit to be sure the finished note is complete and reflects your clinical expertise.
- Seek support. Collaborate with other therapists who are using AI tools in their practice. Seek assistance or tech support from the AI tool provider as needed.
- Consider an all-in-one-solution: If you’re a therapist in private practice with EHR needs, explore EHRs with built-in AI notes and flexible options like text-to text, dictation and even video capture tools. In the long run, you’ll save money with a single solution vs. subscribing to multiple tools. Plus, you’ll save time toggling between software.
What to avoid with AI therapy notes
When using AI tools to automate therapy notes, therapists may want to avoid:
- Over-reliance on AI. Remember that AI does not replace your professional judgement and should be seen as a tool to assist with your processes.
- Compromising PHI: AI tools that do not guarantee HIPAA compliance and strong data security should not be used by therapists.
- Excluding clinical details: Therapists should be sure not to exclude important subjective details in notes such as the client’s emotional state.
AI therapy notes tools can make note-taking more efficient by automating summaries, streamlining dictation, and providing templates for SOAP notes. Using AI for documenting treatment sessions can free up therapists’ valuable time.
Careful considerations should be made when using AI in therapy, such as ensuring that the AI tools used maintain client privacy and that clinical expertise is still reflected. When used appropriately, AI can continue to revolutionize healthcare.
Practice owners can utilize TheraPlatform for more helpful resources. If you own a private practice or are considering starting a private practice, you can use TheraPlatform to manage several aspects of your practice, from documentation to financial organization and scheduling. Consider starting with a free trial of TheraPlatform today and try out its AI-powered intake and notes features.
Streamline your practice with One EHR
- Scheduling
- Flexible notes
- Template library
- Billing & payments
- Insurance claims
- Client portal
- Telehealth
- E-fax
TheraPlatform is an all-in-one EHR, practice management, and teletherapy software with AI intake and notes capabilities built for therapists to help them save time on admin tasks. It offers a 30-day risk-free trial with no credit card required and supports mental and behavioral health, SLPs, OTs, and PTs in group and solo practices.
More resources
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice
- Mental health credentialing
- Insurance billing 101
- Practice management tools
- Behavioral Health tools
Free video classes
- Free on-demand insurance billing for therapist course
- Free mini video lessons to enhance your private practice
- 9 Admin tasks to automate in your private practice
References
Murphy, K., Di Ruggiero, E., Upshur, R., Willison, D. J., Malhotra, N., Cai, J. C., ... & Gibson, J. (2021). Artificial intelligence for good health: a scoping review of the ethics literature. BMC medical ethics, 22, 1-17. DOI: https://doi.org/10.1186/s12910-021-00577-8
Pezold, M. J., Imgrund, C. M., & Storkel, H. L. (2020). Using computer programs for language sample analysis. Language, Speech, and Hearing Services in Schools, 51(1), 103-114. DOI: https://doi.org/10.1044/2019_LSHSS-18-0148
Meier, S. T. (2025). Initial evaluation of an AI‐augmented progress monitoring and outcome assessment. Counselling and Psychotherapy Research, 25(1), e12869. DOI: https://doi.org/10.1002/capr.12869
