What chart notes are
A chart note is any entry in the record that isn't a full visit note. Clinicians, nurses and front desk staff all write them. Most are two to five lines long. Their job is to answer one question for whoever opens the chart next: what happened, and is anyone waiting on anything?
In a therapy practice, chart notes cover the contacts that change care but don't count as a session: a client calling to cancel and mentioning a crisis, a pharmacy asking about a prescription, a parent dropping off school forms, a call to a referring doctor.
Chart notes vs progress notes, case notes and SOAP notes
| | |
|---|
Chart note (this template) | A contact or event between visits, or a correction to the record | |
| One therapy or medical session | |
| Case management contacts, often with outside agencies | A short paragraph per contact |
| A visit, in Subjective, Objective, Assessment, Plan | |
The rule of thumb we use: if you billed for it, write a progress note. If it changed something in the chart or someone's to‑do list, write a chart note.
What goes in a chart note
- Date and time of the contact, and the date you wrote the note if it's different.
- Contact type: phone, portal message, in person, fax, no-show, records release, correction.
- Who was involved: the client, a family member, another provider, a pharmacy. Name them by role.
- What happened and what you did, in plain sentences.
- Follow-up: who owns the next step, and by when. Write "none needed" if that's true.
- Your name, credentials and signature.
Chart note examples
These four chart notes belong to Owen, a fictional 34‑year‑old client seen every other week at an outpatient counseling practice for major depressive disorder, recurrent, moderate (F33.1). They show the four kinds of entry a therapy chart collects most often.
1. No-show
10/07/2026, 2:15 pm. No-show. Owen did not attend his 2:00 pm appointment and did not cancel. Called his mobile at 2:12 pm, left a voicemail asking him to call back and confirming the next slot. Last session on 9/23 noted no safety concerns. Follow‑up: front desk to try again tomorrow morning. Signed, J. Alvarez, LPC.
2. Phone call from the client
10/08/2026, 9:40 am. Phone, incoming. Owen called back. Said he overslept after a night shift and "forgot it was Tuesday." Mood "about the same." Asked directly about thoughts of self‑harm: denied. Rescheduled to 10/10 at 4:00 pm. Follow‑up: none needed. Signed, J. Alvarez, LPC.
3. Coordination with a prescriber
10/09/2026, 11:05 am. Phone, outgoing, to primary care. With Owen's signed release of 6/2026, spoke with the nurse at his primary care office. He has been out of bupropion for five days. Nurse will send the refill to his pharmacy today. Follow‑up: confirm with Owen at the 10/10 session that he picked it up. Signed, J. Alvarez, LPC.
4. Late entry
10/12/2026, 8:30 am. Late entry for 10/10/2026 session. Omitted from the 10/10 progress note: Owen confirmed he picked up bupropion on 10/9 and has taken it daily since. Signed, J. Alvarez, LPC.
The late entry carries both dates and is added below the original note. Nothing in the 10/10 note was changed.
Blank chart notes template
Copy this into your EHR or a document. One block per entry.
Date and time of contact: Date written, if different: Entry type: phone in, phone out, portal, in person, no‑show, records, late entry, correction.
People involved: client, family member, other provider, pharmacy, other. Note the release of information if you spoke with anyone outside the practice.
What happened: The contact in two to four sentences. For a late entry or correction, name the original note and its date.
Risk check, if relevant: what you asked and what the client said.
Follow-up: next step, who owns it, by when. Or none needed.
Name, credentials, signature:
Correcting a chart note the right way
Mistakes in the record get fixed by adding, never by erasing. Medicare's Program Integrity Manual, chapter 3, section 3.3.2.5 expects services to be documented at the time they're given. When an entry has to be amended, corrected or entered later, the date and author of the change should be identifiable and the change clearly and permanently marked. Medicare reviewers look at those entries when they audit a claim.
- Label it: "Late entry", "Correction" or "Addendum".
- Give today's date and the date of the note it refers to.
- Say what's being added or corrected. Leave the original text readable. On paper, a single line through the error with your initials and the date.
- Sign it. The same manual's signature section says a stamped signature is not usually acceptable, with a narrow exception for authors with a disability.
Clients can ask for a correction too. Under 45 CFR 164.526, you have 60 days to act on a written request to amend the record, with one extension of up to 30 days if you tell the client why in writing. If you deny it, the client can file a statement of disagreement, and the request, your denial and that statement are attached or linked to the record. Write a chart note when the request comes in, so the 60 days can be counted.
Common chart note mistakes
- No time on the entry. With two calls on the same day, nobody can tell which came first.
- "Called client" with no outcome. Did you reach them, leave a message, or get no answer?
- No risk check after a no-show for a client whose last note mentioned suicidal thoughts.
- Editing yesterday's progress note instead of adding a late entry.
- Clinical detail in a front desk note. Staff should record the contact and route the clinical part to the clinician.
HIPAA and chart notes
Chart notes are part of the client's record, so the client can request them with the rest of the chart. Before you talk to a pharmacy, a school or another provider, check that a release covers it and mention it in the note, as in example 3.
Chart notes and Twofold
Twofold drafts the session notes, and you can dictate a short summary after a phone call to get a dated chart note you edit and sign. The AI therapy notes page shows how drafts work.
Patient chart template, clinical note template, progress notes template, case notes template, patient notes template and daily note template. For a full contact with a crisis component, use a SIRP note instead of a chart note.
Reviewed and updated October 2026.
