Trauma-Focused CBT Session Note (PTSD)

Date of Service: [date]

Patient: [patient name or ID]

Clinician: [name, credentials]

Session Duration: [start time]–[stop time]; [total psychotherapy minutes] minutes

Modality: [in-person / telehealth] [platform if applicable]

Participants: [patient; family/caregivers with relationship; interpreter if present]

Session Context

[Target symptoms or chief concern for today; diagnoses addressed; treatment protocol and session number or phase; rationale for family/caregiver involvement if present] (Write 2–4 sentences. Summarize trauma themes without graphic details.)

Subjective

(Label information sources: patient-reported vs. collateral. Do not include clinician observations here.)

• [Interval PTSD symptom changes by cluster: intrusions, avoidance, negative cognitions/mood, hyperarousal]
• [Functional status: work/school, relationships, ADLs, sleep]
• [Home practice completion: what was assigned, what was completed, barriers encountered]
• [Symptom measure scores with comparison to prior if available]
• [Significant intervening events: new triggers, safety incidents, medication changes, ER visits] (Include only if applicable.)

Objective

MSE: [appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, insight, judgment]

Session observations: [engagement level, tolerance of therapeutic work, dissociation signs and grounding response if applicable, family interaction quality if applicable]

Interventions

• [Therapeutic techniques used: psychoeducation, cognitive restructuring, exposure work, relaxation/grounding, caregiver coaching, communication training] (List only those delivered this session.)
• [Protocol-specific details: For PE: exposure type, duration, distress ratings. For CPT: stuck points addressed, worksheets used, cognitive shifts. For TF-CBT: component/phase, caregiver skill work, conjoint content.] (Include only elements actually used.)
• [Patient and family response: engagement, affect modulation, skill use, notable shifts]

(Summarize trauma themes without graphic narrative detail.)

Assessment

[PTSD symptom trajectory with supporting evidence; progress toward treatment goals with observable anchors; impact of comorbidities; fit to treatment plan and medical necessity; protocol pacing adjustments if any] (Write 3–5 sentences.)

Risk Assessment

Suicide risk: [ideation, plan, intent, behaviors, access to means, protective factors] (If not assessed, document "Not assessed" with brief rationale.)

Violence risk: [ideation, plan, intent, access, precipitants, protective factors] (Include if clinically indicated; otherwise omit or note "Not indicated.")

Other safety concerns: [self-injury, abuse/neglect, unsafe environment, substance use, severe dissociation] (Include only applicable concerns.)

Risk level: [low / moderate / high]; [brief rationale]

Safety plan: [If elevated risk: key elements reviewed/updated, means restriction, crisis resources. If low risk: "Safety plan not indicated" or "Existing plan reviewed, no changes."]

Plan

Home practice: [specific assignments with frequency/duration; caregiver support role; anticipated barriers and strategies]

Next session: [planned content, date/time or scheduling status]

Coordination: [communication with other providers, referrals, releases needed] (Omit if no coordination occurred.)