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Treatment Plans & Session Notes

Treatment Plans & Session Notes

Treatment Plans

A treatment plan is the structured clinical record of a client's presenting issues and the practitioner's recommended approach. It is created once per client and updated as the work progresses.

Creating a Treatment Plan

  1. Open the client record → Treatment Plan tab
  2. Click New Treatment Plan
  3. Fill in the structured fields:
Field Description
Status draft, active, or completed
Presenting Issues What the client came in with, in their words
Primary Conflict The root biodecoding conflict identified
Emotional Patterns Key recurring emotional themes
Recommended Approach Your proposed methodology and interventions
Session Recommendations How many sessions, what frequency
Risk Factors Any safeguarding or risk considerations
Practitioner Notes Internal notes not shared with client
Review Date When to formally review the plan
  1. Add Goals — enter short-term, medium-term, and long-term goals as line-separated text. Each line becomes an individual goal record.
  2. Click Save Treatment Plan

Updating a Treatment Plan

Open the existing plan and click Edit. Update any field and save. Goal status can be updated individually (open → in progress → completed).

Session Notes

Structured session notes capture what happened in each practitioner session. They are separate from the AI chatbot session records.

Creating Session Notes

  1. Open the client record → Notes tab
  2. Click Add Session Note
  3. Complete the structured fields:
Field Description
Presenting Issue What the client brought to this session
Key Themes Main emotional or behavioural themes explored
Interventions What techniques or approaches were used
Client Response How the client responded — engagement, resistance, breakthroughs
Homework Any tasks or reflections set for between sessions
Risk Flags Any safeguarding concerns that arose
Next Session Focus What to prioritise next time
  1. Click Save Notes

Notes are stored against the client record and visible only from the admin panel.

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