This article is intended for:
🧑⚕️ Providers
Session notes are an important part of providing safe, consistent, and high-quality care. They help maintain continuity between sessions, support clinical decision-making, and ensure there is an appropriate record of the care provided.
All session notes must be recorded using the built-in session notes feature within the MindFi platform. This feature is HIPAA compliant and designed to support secure clinical documentation.
Providers are expected to complete session notes within 48 hours after each session, ideally while details are still fresh.
Why session notes are important
Recording session notes helps to:
Maintain continuity of care across sessions
Track progress, themes, and agreed action points
Support risk management and clinical decision-making
Provide appropriate documentation for operational and compliance purposes
Ensure important context is available if consultation or escalation is needed
Session notes should be objective, professional, and relevant to the care provided during the session.
Confidentiality of session notes
Session notes are treated as strictly confidential.
They are only accessible to the Provider who created them, except where access is required by specific authorized MindFi staff on a need-to-know basis for operational, clinical, safeguarding, legal, or compliance purposes.
Providers should ensure that all documentation remains professional, accurate, and appropriate for clinical records.
Where to record session notes
To record session notes:
On the Bookings tab, find the specific session, then click on Session Details
Click on Add Note
Enter your notes and save your changes
Session notes should be completed within 48 hours after the session.
Where to view & edit past session notes
To view session notes for a specific member:
On the Members tab, search for the specific member, then click on View More
Go to the Notes sub-tab to view notes for all previous sessions
To edit previous notes, go to the Sessions sub-tab, find the specific session, and click on Add Note
What session notes should include
Session notes should contain a concise summary of the session and any clinically relevant information. Providers may use their own preferred documentation format, as long as the notes remain appropriate for clinical documentation.
Depending on the nature of the session, notes may include:
Presenting concerns or topics discussed
Key observations or themes identified during the session
Interventions, strategies, or approaches used
Progress since previous sessions
Action plans or goals discussed with the member
Any risk concerns, safeguarding considerations, or escalation actions taken
Recommendations or follow-up plans, if applicable
Notes should be concise, clear, factual, and professional in tone.
Important guidelines
When recording session notes:
Avoid including unnecessary personal details that are not relevant to care
Do not include discriminatory, judgmental, or inappropriate language
Ensure documentation is accurate and completed in a timely manner
Follow all applicable professional, ethical, and legal documentation standards in your jurisdiction
Risk-related situations
If a member presents with moderate to high risk, please follow the appropriate crisis escalation protocols immediately and document the relevant details in your session notes. Do not delay escalation while waiting to complete documentation.