Document the thinking, not just the session: What the Lindsay Clancy trial can remind therapists about session notes

This is part 2 of a 3-part series for mental health therapists and their supervisors. I am a Registered Psychotherapist in Ontario, Canada and have been practicing for 20+ years. I have an active supervision practice and the topic of the Lindsay Clancy trial is coming up in most of my supervision sessions. This series represents my attempt to clarify the issues relevant to Psychotherapists and provide my perspective on how Psychotherapists can mindfully improve their practice while staying out of the anxiety loops that a trial like this can cause for professionals. My perspective reflects the role and scope of Registered Psychotherapists in Ontario and may not apply directly to other jurisdictions.

-Carly Fleming, M.Ed., RP

In the Lindsay Clancy trial, jurors have heard testimony focusing on the way a psychiatrist documented sessions with Lindsay prior to the tragedy resulting in the loss of her 3 children’s lives. One defense attorney characterized the documentation style of a treating clinician as box-checking. Mental health professionals are watching this trial with great interest and the issues it’s highlighting around session documentation are showing up in many of my supervision sessions. The reality is, documentation is hard. Therapists are over-extended and under-resourced, and even without those pressures, documentation is a genuinely difficult skill to master. What I have noticed in the testimony around this case and in my supervision conversations is that while therapists are often trained to chart efficiently and describe the session itself, we are almost never trained to document our thinking.

The three things a good note actually needs

A useful clinical note (the kind that protects the client, serves the clinical work, and protects the therapist at the same time) tends to have three components:

1. What came up. The presenting issues, symptoms, disclosure, or topics arising in this particular session.

2. Your clinical reasoning about it. What you made of it, why you responded the way you did, what you considered and ruled out.

3. What you actually said or did. The intervention, the referral, the safety plan, the homework.

Most therapists understand how to document #1 and #3. Competency in documenting what came up and what took place in the session are essential to competent practice. But in addition to these components, the middle piece - the why - is the part that is often skipped during training and also the part that matters most when a case gets complicated.

This isn't just best practice, it's in the standard

The College of Psychotherapists of Ontario (CRPO) indicates that clinical records must capture more than what a client said and what the therapist did - it explicitly requires the therapist to document their “observations, impressions and proposed plans in response”.In my work with supervisees, I interpret this to mean that the College expects the reasoning layer to be documented in the chart. Because this is the hardest part to document (it’s really hard to take the decisions we make in our minds and outline them in a note), it’s often the part we skip when we're short on time.

Why the middle piece is the one that protects everyone

If a client later experiences a crisis, a hospitalization, or something worse, your notes get read by people who weren't in the therapy room: a supervisor, a lawyer, a coroner's inquest, a College inquiry board. What they're trying to reconstruct isn't just "what did the therapist observe" — it's "was the therapist's judgment sound, given what they knew at the time." A note that only records symptoms and interventions leaves that question unanswerable. A note that also records your reasoning, for example “I considered referring to a psychiatric consult here but I held off because X, and planned to reassess at the next session”  answers it in your own words, at the time, rather than leaving you to reconstruct your thinking under pressure months or years later.

This is also, not coincidentally, where scope of practice and documentation meet. If you had a conversation with a client about the limits of your competence, or about needing to refer to a different practitioner, that conversation needs to exist somewhere other than your memory of having had it.

Nuance is hard to document

Nuanced and careful documentation does take more time than a checklist, in the moment. But undocumented thinking has its own cost that we rarely acknowledge. It can show up later when records are requested or it can sit quietly in the back of a therapist’s mind resulting in anxiety, imposter syndrome and a general sense that you may not be offering the best care to your clients.

The way to solve this isn't spending twice as long on every note. It's developing an efficient shorthand for reasoning, the same way you already have shorthand for client disclosures and interventions. A single sentence, for example “Screened for suicidal ideation, denied by client; monitoring given recent sleep disruption and family stress” captures reasoning in about the same space as a checkbox and can be just as quick, once it becomes a habit.

When does a note need more detail?

Not every session needs three paragraphs of clinical reasoning. Most don't. The judgment of when extra detail is warranted - a risk indicator, a scope question, a sudden shift in presentation, anything that made you pause even slightly - is something that develops with experience. It can take some time for therapists to develop the instinct for which sessions are "routine documentation" and which ones deserve the extra two minutes.

This is exactly what supervision and case consultation are for. Every therapist, at every level, needs it in difficult cases. And importantly, the consultation itself must get documented too - the date, who you consulted, what was discussed, what you decided and why. That record is often what turns "I wasn't sure what to do, so I got help" from an invisible act of good clinical judgment into a visible one.

Next in this series: how a therapist can approach medication conversations when they come up in session.