The Brief Session Note is a concise clinical record summarizing the key elements of a psychiatric or therapeutic encounter. It typically includes a focused update on the patient’s current mental status, symptom changes, medication adherence, interventions provided, and short-term goals. Unlike a comprehensive note, it emphasizes clarity and efficiency without sacrificing clinical value.
For psychiatric NPs, the brief session note is particularly useful for routine follow-ups or check-in appointments where time is limited but documentation remains essential. It supports continuity of care, meets legal and billing requirements, and allows for quick reference at subsequent visits. Its brevity ensures that the clinical focus remains on the patient while still capturing essential treatment data.