NHS Psychology Documentation Standards & Templates

What Is NHS Psychology Documentation?

NHS psychology documentation encompasses all clinical records created by psychologists working within the National Health Service — session notes, assessment reports, care plans, outcome measures, correspondence, risk assessments, and discharge summaries. These records serve multiple purposes: clinical continuity, patient safety, clinical governance, legal protection, research, and service evaluation.

Documentation within the NHS operates in a fundamentally different context from private practice. Your notes are part of the patient's shared NHS health record, accessible to authorised members of the multidisciplinary team (MDT). They exist within an electronic patient record system mandated by your trust. They are subject to clinical audit, patient access requests under UK GDPR, and scrutiny in complaint investigations, coroner's inquests, and legal proceedings.

The standard expected of NHS psychology documentation is that a competent colleague who has never met the patient could read your records and understand the patient's presentation, your clinical formulation, the treatment being delivered, the patient's progress, and any risks. Your notes are not personal aide-memoires — they are professional clinical documents that exist within a healthcare system.

For psychologists trained in the tradition of detailed, reflective clinical notes, the NHS context requires a shift. Your notes must be clear, concise, and clinically focused. The MDT nurse, psychiatrist, or social worker reading your entry needs to quickly understand the patient's current state and any actions required — not read through three pages of therapeutic process narrative.

When You Need It

You create NHS clinical documentation in every aspect of your NHS practice:

• Every clinical contact — face-to-face sessions, telephone contacts, video consultations, and any clinical interaction must be documented in the patient's electronic record
• Assessment and formulation — initial psychological assessments, formulation letters (often shared with patients), and diagnostic opinions
• Treatment planning — documented treatment plans that specify the modality, anticipated number of sessions, goals, and outcome measures
• Risk assessment and management — documented at assessment, at any point of change in risk, and as part of ongoing care
• Multidisciplinary communications — letters to GPs, MDT meeting contributions, ward round entries, and care plan contributions
• Discharge and transfer — discharge summaries and transfer letters when the patient leaves your service or moves to another team
• Clinical supervision — documentation of supervision discussions, decisions, and reflective practice (kept separately from patient records)

Key Components / Requirements

Electronic Patient Records

All NHS trusts use electronic patient record (EPR) systems. Common systems include RiO (used by many mental health trusts), SystmOne, EMIS, and Carenotes. Your clinical entries must be made directly into the trust EPR system — not kept in separate personal files. All entries are date-stamped, time-stamped, and linked to your HCPC registration. Late entries should be marked as such and the reason for the delay noted.

Session Note Content

NHS psychology session notes should include:

• Date, time, and duration of the contact
• Mode of contact — face-to-face, telephone, video
• Location — clinic, ward, community, patient's home
• Who was present — patient, family members, interpreter, co-therapist
• Clinical content summary — the focus of the session, interventions delivered, and patient response. Be specific enough to demonstrate clinical competence but concise enough for MDT readability
• Outcome measures — scores from any standardised measures administered (PHQ-9, GAD-7, CORE-OM, etc.)
• Risk — current risk status, any changes in risk, and management actions taken. If risk was assessed and found unchanged, a brief statement to this effect is sufficient
• Plan — actions for the patient (homework, between-session tasks), actions for the clinician (referrals, letters, MDT discussions), and the date of the next appointment

NICE Guideline Alignment

NICE clinical guidelines provide evidence-based recommendations for the treatment of specific conditions. When documenting treatment, reference the relevant NICE guideline and note whether your treatment aligns with it. Common NICE guidelines relevant to psychology include:

• CG90/CG91 — Depression in adults (updated as NG222)
• CG113 — Generalised anxiety disorder and panic disorder
• CG26 — PTSD (updated as NG116)
• CG31 — OCD and BDD
• CG178 — Psychosis and schizophrenia
• NG87 — Eating disorders
• CG78 — Borderline personality disorder

Risk Documentation

Risk documentation in the NHS is not optional. Every assessment should include a risk screen, and risk should be reviewed regularly throughout treatment. Document risk using the trust's risk assessment template or framework. Most trusts use structured professional judgement, not actuarial tools alone. Document risk factors, protective factors, your risk formulation, and your management plan. If a patient is on the trust's risk register, ensure your entries reflect current risk status.

Formulation Letters

A distinctive feature of UK clinical psychology practice is the formulation letter — a written formulation shared with the patient (and often the referrer) that summarises the assessment, presents the psychological formulation, and outlines the proposed treatment plan. This practice reflects the BPS emphasis on formulation as a core competency and the NHS commitment to patient involvement in care. Formulation letters should be written in accessible language, collaboratively developed with the patient, and filed in the clinical record.

Discharge Summaries

When a patient completes treatment or is discharged from the service, a discharge summary should be sent to the GP (and any other relevant professionals) and filed in the clinical record. The discharge summary includes the diagnosis or formulation, the treatment delivered, outcome measure results, the patient's status at discharge, relapse prevention plans, and recommendations for ongoing care.

How to Write It

Step 1: Write contemporaneously. Enter your notes into the EPR system on the same day as the clinical contact. NHS trusts typically expect same-day documentation. If this is not possible, enter the note the next working day and mark it as a late entry.

Step 2: Write for the MDT. Your notes will be read by psychiatrists, nurses, social workers, and other professionals who need to quickly understand the patient's current clinical status. Be concise. A well-written session note in the NHS should be 200 to 400 words — enough to capture the clinical essentials without overwhelming the reader.

Step 3: Include outcome measures at every session. This is increasingly expected across NHS mental health services, not just in IAPT. Routine outcome monitoring demonstrates treatment effectiveness and supports clinical governance reporting. Record the score, the previous score, and the baseline score so that trajectories are visible at a glance.

Step 4: Document risk at every contact. Even if risk has not changed, document that risk was assessed and remains at the same level. If risk has changed, document the change, your formulation of the change, and the actions you have taken (or will take) in response.

Step 5: Reference NICE guidelines. When describing your treatment approach, note the relevant NICE guideline. This is straightforward when delivering NICE-recommended treatments (e.g., trauma-focused CBT for PTSD per NG116) and important when you are using an alternative approach — document your clinical rationale for the deviation.

Step 6: Copy letters to the patient. Under NHS policy and good practice guidance, letters about a patient should be copied to the patient unless there is a specific reason not to (such as safeguarding concerns). Write your letters accordingly — clearly, respectfully, and without jargon that the patient would not understand.

Common Mistakes

• Keeping separate personal notes outside the EPR. All clinical information must be recorded in the trust's electronic patient record. Separate personal notes create legal and governance risks — they are still discoverable in legal proceedings but exist outside the trust's information governance framework.
• Writing notes that only a psychologist would understand. Your MDT colleagues need to understand your notes. Avoid unexplained jargon, lengthy theoretical formulations in session notes, and process descriptions that do not convey clinically actionable information.
• Failing to document risk. In the event of a serious incident, the first thing reviewed will be your clinical records. If risk was not documented, the assumption will be that risk was not assessed — regardless of what you actually did in the session.
• Not recording outcome measures. NHS trusts and commissioners increasingly require routine outcome monitoring data. Failing to record outcome measures creates gaps in service evaluation data and may affect the trust's ability to demonstrate treatment effectiveness to commissioners.
• Ignoring trust-specific documentation policies. Each trust has local documentation standards, templates, and deadlines. Familiarise yourself with these when you start and follow them consistently. "I didn't know" is not an adequate defence in a governance review.
• Delaying discharge summaries. GPs rely on discharge summaries to understand what treatment was provided and what ongoing care is recommended. Delayed discharge letters leave the GP without the information they need to continue supporting the patient.