Facebook tracking pixelEye Movement Desensitization and Reprocessing Documentation
Back to Templates
Psychiatric Specialist
30-45 minutes

Eye Movement Desensitization and Reprocessing Documentation

The EMDR Note template by s10.ai is an all-encompassing documentation tool crafted for psychiatrists and mental health professionals focusing on trauma therapy. This template streamlines the recording of comprehensive client data, subjective experiences, and objective clinical evaluations during Eye Movement Desensitization and Reprocessing (EMDR) sessions. It features sections for capturing psychological and biological factors, therapeutic interventions, and client progress. Utilizing this template with s10.ai enables clinicians to efficiently monitor treatment responses and strategize future sessions, ensuring a systematic approach to trauma recovery. This template is perfect for those aiming to elevate their EMDR therapy documentation practices.

4,948 uses
5/5.0
D
Dr. Michael Thompson
Template Structure

Organized sections for comprehensive clinical documentation

Client Details:
- Client Name: [Insert client name here] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- Provider Name: [Insert provider name here] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- Date of Service: [Insert date of service here]
- Session Duration: [Insert session duration here]
SUBJECTIVE:
Presentation:
- Chief Concern: [Describe the client’s main issue and reason for seeking therapy. Example: "Client reports ongoing issues with anxiety and fear related to a past traumatic event in which they were attacked and mugged at knifepoint."]
- Impairments and Challenges: [Describe how the traumatic memory impacts the client’s daily functioning, emotional state, or sense of safety. Example: "The client describes feelings of terror, powerlessness, and fear when recalling the event."]
Psychological Factors:
- Symptom Description: [Describe the primary symptoms tied to the trauma, including onset, frequency, intensity, and duration. Example: "Recurrent and distressing recollections of the traumatic event in the form of vivid sensory memories and imagery."]
- Image Details: [Detail the sensory components of the traumatic memory and emotional response tied to it. Example: "Client reported visual image of assailant holding a knife as the most disturbing aspect of the memory."]
- Negative Cognition: [Insert negative belief tied to the memory, e.g., "I'm powerless."]
- Positive Cognition: [Insert desired positive belief, e.g., "I can handle myself."]
- Emotional Processing: [Document emotional changes during the session. Example: "Initially felt 'terrified,' but after processing, reported feeling 'relief.'"]
Biological Factors:
- Body Sensations: [Document physical sensations tied to trauma recall, e.g., "Client reported chest tightness during memory recall."]
OBJECTIVE:
Clinical Assessment:
- Assessment Tool: [Document tools used, e.g., "Clinical Interview."]
- Results: [Summarize findings, if applicable.]
- Status: [Document the assessment status, e.g., "Ongoing assessment."]
- Validity of Cognition Rating: Initial: [Insert score] /7; Final: [Insert score] /7
- SUDs Rating: Initial: [Insert score] /10; Final: [Insert score] /10
Interventions:
- Therapeutic Approach or Modality: [Document the therapeutic approach used, e.g., "Eye Movement Desensitization and Reprocessing (EMDR)."]
- Therapeutic Interventions: [Summarize interventions employed, such as bilateral stimulation, cognitive restructuring, or reviewing traumatic memory from different perspectives.]
- Rationale: [Explain the reasoning behind the chosen interventions, e.g., "To reduce disturbing emotions and beliefs tied to the traumatic memory and help the client feel safer and more in control."]
ASSESSMENT:
Progress and Response:
- Response to Treatment: [Document the client’s response, including changes in distress levels and beliefs. Example: "Client reported SUDs dropping from 8 to 0 and validity of cognition rising from 2 to 7."]
- Quote (Progress): [Insert direct client quote if available.]
- Processing Response: [Describe client engagement during processing and any insights or memory shifts observed.]
- Reprocessing Effects: [Summarize effects of reprocessing, including emotional, cognitive, or sensory changes. Example: "Client reported relief, decreased disturbance, and increased belief in positive cognition."]
PLAN:
Follow-Up Actions and Plans:
- Homework: [Document homework assigned, e.g., "Client instructed to keep a diary of new insights or memories arising after session."]
- Plan for Future Session: [Summarize planned focus for the next session, e.g., "Continue trauma processing, targeting new elements identified in homework."]
- Plans for Continued Treatment: [Document overall treatment goals and frequency of sessions, e.g., "Continue weekly trauma processing sessions to reduce PTSD symptoms and increase emotional functioning."]
- Coordination of Care: [Document any coordination with other providers, if applicable, or "No coordination of care indicated at this time."]
Sample Clinical Note

Example of completed documentation using this template

Client Information:
- Client Name: John Doe
- Provider Name: Dr. Emily Smith
- Date of Service: 1 November 2024
- Session Duration: 60 minutes
SUBJECTIVE:
Presentation:
- Chief Complaint: Client reports persistent anxiety and fear stemming from a past traumatic incident involving a car accident.
- Impairments and Challenges: The client describes experiencing terror, helplessness, and fear when recalling the event, affecting their ability to drive or ride in a vehicle.
Psychological Factors:
- Symptom Description: Frequent and distressing recollections of the traumatic event, characterized by vivid sensory memories and imagery.
- Image Details: Client identified the visual image of the car crash as the most distressing part of the memory.
- Negative Cognition: "I'm not safe."
- Positive Cognition: "I can protect myself."
- Emotional Processing: Initially felt 'terrified,' but after processing, reported feeling 'relief.'
Biological Factors:
- Body Sensations: Client reported chest tightness during memory recall.
OBJECTIVE:
Clinical Assessment:
- Assessment Tool: Clinical Interview.
- Results: Client exhibits symptoms consistent with PTSD.
- Status: Ongoing assessment.
- Validity of Cognition Rating: Initial: 2/7; Final: 6/7
- SUDs Rating: Initial: 8/10; Final: 1/10
Interventions:
- Therapeutic Approach or Modality: Eye Movement Desensitization and Reprocessing (EMDR).
- Therapeutic Interventions: Bilateral stimulation and cognitive restructuring.
- Rationale: To alleviate disturbing emotions and beliefs associated with the traumatic memory and help the client feel safer and more in control.
ASSESSMENT:
Progress and Response:
- Response to Treatment: Client reported SUDs decreasing from 8 to 1 and validity of cognition increasing from 2 to 6.
- Quote (Progress): "I feel like I can finally breathe again."
- Processing Response: Client was engaged during processing and reported a shift in memory perception.
- Reprocessing Effects: Client reported relief, decreased disturbance, and increased belief in positive cognition.
PLAN:
Follow-Up Actions and Plans:
- Homework: Client instructed to keep a diary of new insights or memories arising after session.
- Plan for Future Session: Continue trauma processing, targeting new elements identified in homework.
- Plans for Continued Treatment: Continue weekly trauma processing sessions to reduce PTSD symptoms and increase emotional functioning.
- Coordination of Care: No coordination of care indicated at this time.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for mental health professionals addressing trauma-related cases. By incorporating high-search healthcare and clinical keywords, this template ensures that clinicians can efficiently capture critical client information, including subjective experiences, psychological and biological factors, and objective clinical assessments. The template facilitates detailed documentation of therapeutic interventions, such as Eye Movement Desensitization and Reprocessing (EMDR), and tracks client progress and response to treatment. With sections dedicated to follow-up actions and plans, this template supports ongoing treatment goals and coordination of care. Clinicians are encouraged to adopt this template to enhance their practice, improve patient outcomes, and ensure thorough, SEO-optimized clinical documentation.
Frequently Asked Questions

Common questions about this template and its usage

Ready to transform your practice?

Join thousands of clinicians already using S10.AI to reduce administrative burden and improve patient care.

Cookie Preferences

We use cookies to enhance your browsing experience, analyze site traffic and personalize content.