EMDR Note Template with Examples

EMDR Note Template

This AI-powered EMDR Note Template is a comprehensive documentation tool designed for psychiatrists and other mental health professionals specializing in trauma therapy. Through Heidi, our AI-powered medical scribe, you can easily use this template to:

• Capture essential client information, as well as their subjective experiences and objective clinical assessments to inform EMDR sessions. 
• Track psychological and physiological responses during EMDR therapy, including distress levels, cognitive shifts, and emotional processing outcomes. 
• Document treatment interventions, progress assessments, and follow-up plans to ensure structured and effective trauma processing sessions.
  

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What is an EMDR Note Template?

An EMDR (Eye Movement Desensitization Reprocessing) Note Template is a structured documentation tool used by mental health professionals to record therapy sessions that utilize the EMDR approach. EMDR is a psychotherapy technique designed to help patients process traumatic memories and reduce stress.

In this article, we’ll discuss the importance of EMDR note templates, provide tips on how you can use EMDR notes effectively, and share a detailed step-by-step guide to writing EMDR notes. Most importantly, we’ll be sharing free and customizable AI-enabled templates you can use to create EMDR notes for your practice. 

Why are EMDR Note Templates Important?

EMDR Note Templates ensure consistent and comprehensive documentation. They guide therapists so they can accurately capture key session details to ensure continuity of care.

Using a template also improves efficiency and reduces administrative burden so mental health professionals can focus more on client care rather than extensive paperwork. Finally, it helps therapists maintain HIPAA compliance and meet professional documentation guidelines. 

How to Use EMDR Notes Effectively

EMDR notes are essential for proper documentation, but they’re even more important for tracking patient progress and ultimately ensuring effective therapy. Here’s how to maximize their usefulness:

Review EMDR Notes to Track Progress and Personalize Treatment

Therapists typically create one EMDR note per session. This means you can review past notes to track potential patterns in how clients respond to different interventions. Look for recurring negative or positive cognitions, emotional shifts, and physical sensations, then use the identified patterns to refine treatment strategies moving forward.

Enhance Client Engagement with Structured Feedback

Keeping clients engaged and invested in the treatment process is a great way to improve adherence and boost treatment success rates. You can do this with EMDR notes by sharing key progress points such as reduced distress scores and positive cognition shifts to reinforce their growth.

Reinforcing past breakthroughs is a good way to keep clients motivated, especially when some EMDR sessions prove to be more challenging than others. To keep their momentum going, you can also incorporate structured reflection exercises to help clients process their experiences productively between sessions.

Improve Communication and Collaboration with Healthcare Providers

Well-structured EMDR notes can support better coordination with other healthcare providers, ensuring a holistic approach and high-quality care continuity. They also make it easy to summarize key therapy milestones in reports when referring a client or collaborating on treatment planning. 

Maintain Long-Term Case Documentation for Future Sessions

Securely storing your EMDR notes allows long-term tracking of complex trauma cases. This way, you can use them to monitor relapse risks and develop long-term coping strategies for your clients. Having ready access to past EMDR notes also allows you to ensure continuity of care for your returning clients, even after long gaps between sessions.

Dr. Tony Fernando, a New Zealand-based psychiatrist, saves two hours each day with the help of Heidi’s AI medical scribe. “The biggest source of my stress is not patients–it’s documentation.”

After just two months of using Heidi, he cut his documentation time by more than half without compromising quality and patient care. ”The difference with Heidi is instantaneous. It’s real-time, and then after the consultation, I just click stop recording and then generate.”

“I’ve been recommending Heidi left and right. Considering I’m a technophobe–people are surprised!”

Step-by-Step Guide to Writing EMDR Notes

An effective EMDR note follows a structured format that covers the key details, including subjective experiences, objective assessments, interventions, progress, and future plans. Read our guide below so you can create and customize your EMDR notes while ensuring they remain thorough and useful for your daily practice:

Step 1: Start With Essential Client Information

First, record the client’s name, the provider’s name, the date of the session, and the session’s duration. If necessary, note any pre-session observations such as the client’s initial mood or any concerns expressed prior to starting the EMDR processing.

Step 2: Document the Client’s Subjective Experience

Summarize the client’s chief complaint like anxiety, trauma-related distress, and any functional impairments affecting daily life. Describe symptom details, sensory memories, and imagery, then document the most disturbing image or moment recalled during EMDR processing.

Next, record the client’s negative cognition (“I’m not safe”), and their desired positive cognition (“I can protect myself.”) 

In the same section, track emotional shifts such as their starting emotional state vs. their emotions after EMDR processing, then note physical sensations reported by the client such as chest tightness, headaches, and nausea during processing.

Step 3: Provide an Objective Clinical Assessment

After documenting the client’s subjective experiences, include an objective clinical assessment to provide a fuller picture of their mental state and treatment progress. You can start by noting the assessment tools used during the session then summarize key observations related to the client’s emotional, cognitive, and physiological responses.

To round this section out, note your diagnostic impressions if applicable. For example, if they have symptoms consistent with PTSD, make sure to document it. You can do the same for Validity of Cognition (VoC) scores and Subjective Units of Distress (SUDs) scores where they apply.

Step 4: Describe the EMDR Intervention Used

Clearly indicate that EMDR was the primary therapeutic approach used for the session. Go into further detail by describing the bilateral stimulation techniques applied during the session. Below are some of the most common techniques utilized in practice:

• Eye movements – The therapist guides the client’s eyes back and forth by having them follow a moving object such as their finger or a light. This technique is meant to mimic the natural eye movements experienced during REM sleep, which helps the brain process and reframe traumatic memories. 
• Tapping – The therapist alternates light taps on the client’s hands, shoulders, or knees to provide sensory input. This helps ground them so they can stay engaged as they process distressing memories without being emotionally overwhelmed. 
• Auditory tones – The client is asked to listen to alternating tones between their left and right ears through headphones. The aim is to stimulate the two hemispheres of the brain so that clients can process traumatic memories while lowering their emotional distress response.  

Step 5: Assess Progress and Treatment Response

Document how the client subjectively perceives the effects of the EMDR session. Ask whether they experienced relief, increased confidence, or reduced emotional distress, then note their response. Include any direct statements from the client that reflect meaningful progress or emotional breakthroughs. For example, “I feel like I can finally breathe again.”

Note their engagement levels during EMDR processing and whether they appeared receptive, resistant, or highly emotional.

Lastly, summarize any notable changes in their perception of the traumatic memory, emotional intensity, and confidence in positive cognitions.

Step 6: Outline Follow-Up Actions and Next Steps

In the final section, note and assign reflection exercises for the client such as journaling insights or tracking emotional responses. Then, identify potential trauma elements that need to be processed or other areas needing further attention for future treatment.

To finalize your EMDR note, outline the continued focus of future EMDR therapy sessions, and mention if referrals or additional consultations with other healthcare providers are needed to maximize the effectiveness of treatment and intervention plans. 

EMDR Note Template Example

Here’s a free sample EMDR Note Template in PDF and Google Doc Form:

EMDR note templates are typically filled out manually. While this traditional approach can be effective, it doesn’t safeguard healthcare providers from accidentally documenting incorrect information or missing key details.

Fortunately, an AI-powered solution can now help mental health professionals streamline EMDR documentation automatically. By reducing administrative burdens, these advanced tools allow providers to focus more on their clients and deliver higher-quality care. 

Easily Create EMDR Note Templates with Heidi

Heidi is our cutting-edge AI medical scribe designed to help healthcare providers fill out EMDR Note Templates in real-time. With your patient’s permission, simply hit record and let Heidi work as you go. Here’s how Heidi helps you complete your EMDR notes:

• Transcribe – Open Heidi on your computer or mobile device and press Start so Heidi can capture your conversation in the background. For information that you don’t want to verbalize, you can type it under context notes to be considered later.
• Customize – Post-session, simply select your preferred EMDR note template and watch as Heidi perfectly transcribes the details of your conversation and context notes in the appropriate format!
• Transform – After generating your completed EMDR note templates, you can ask Heidi to give additional documentation including progress notes or treatment summaries as needed.
  

Heidi complies with jurisdiction-specific regulations, ensuring data localization for customers in Australia, Canada, the United States, the United Kingdom, and beyond. Read more about our compliance here.

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Free EMDR Note Template for Client Progress

EMDR Note Template for Treatment Sessions

This EMDR session template is designed for pediatric psychologists to document therapy sessions with children. It includes sections for summarizing the patient’s current state, session focus, and techniques used, along with detailed descriptions of target images, cognitions, and emotional responses. 

View Template

EMDR Note Template for Client Progress

This EMDR notes template is specifically designed for therapists specializing in trauma therapy. It aims to comprehensively document the EMDR process, including phases like desensitization, installation, and closure. The template also captures key details such as negative and positive cognitions, emotions, and body sensations, providing a structured approach to tracking client progress. 

View Template

FAQs About EMDR Note Templates

Are digital EMDR note templates HIPAA-compliant?

Yes! Digital EMDR note templates can be HIPAA-compliant if stored and transmitted through secure and encrypted platforms that follow healthcare privacy regulations. Aside from being HIPAA compliant, Heidi complies with numerous global standards for data-handling quality and security.

Which essential sections should every EMDR note template have?

An effective EMDR note template should include the client’s information, subjective experiences, and objective clinical assessments during the session, therapeutic interventions used, their treatment response, and any follow-up plans. Covering these key areas ensures consistent, comprehensive, and structured documentation. 

What are the most common mistakes therapists make when writing EMDR notes?

Common mistakes include omitting key session details, using vague or subjective language, and failing to track progress using measurable data types like SUDs and VoC scores. Failure to comply with HIPAA-approved documentation practices and other relevant, location-specific regulatory requirements are also critical mistakes that must be avoided to avoid ethical and legal consequences for your healthcare practice.