The Five W's Who, What, Where, Why, and When

Be careful in your language about whether or not something is concrete. I probably would only say that they are excited if the person explicitly said, I am excited. The next piece of information that I want to see in notes pertains to interventions. What treatment interventions did you use and what was a clinical reasoning behind them? One thing I often hear from different insurance companies about this is that it doesn't really give indication for what the therapist is doing and why.