Can a recovery coach or mental health support worker write clinical notes?

No — recovery coaches and mental health support workers write support notes, not clinical notes. Your note should record what was discussed, how the person engaged, and agreed actions. It should not include diagnoses, clinical assessments, or interpretations that fall outside your scope of practice. If you have clinical concerns, escalate to the appropriate clinician.

How should I describe a person's mood in a support note?

Use observable, objective language rather than clinical terms or assumptions. For example, 'client reported feeling low' or 'client's speech and engagement were noticeably more animated by the end of the session' is clearer and more accurate than 'client was depressed' or 'client seemed happier'. Describe what you saw or what the person said — not what you think they were feeling.

Do I always need to record risk in a mental health support note?

Yes. A good mental health support note always includes a brief risk statement, even if there were no concerns — for example, 'no risk concerns were raised or observed during this session'. This protects you and supports any clinician who reviews the notes later. If a risk concern was raised or observed, record what happened and what action you took, and escalate according to your provider's process.

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Rough note

recovery coach session talked about going back to study low mood at start brighter by end agreed next steps

Clearer note

Attended scheduled recovery coaching session with client. Client reported low mood at the start of the session, describing feeling uncertain about their goals. During the session, the client and worker discussed the client's interest in returning to study and identified practical first steps. By the end of the session, client's engagement and verbal communication were noticeably more animated. Client agreed to follow up on one identified action before the next session. No risk concerns were raised or observed.

A clear mental health support note records what was discussed, how the person engaged, and any agreed next steps — without labelling, diagnosing, or interpreting. This protects you and supports continuity of care.

Describes engagement and mood in observable, objective terms
Records agreed actions without promising outcomes
Notes risk status clearly — including when no concerns were raised

What to include

The type of session and who attended
What the person reported or discussed (their words, not your interpretation)
Observable changes in engagement, affect, or communication during the session
Any agreed actions or next steps the person committed to
Risk status — whether concerns were raised or not, and any action taken

What not to write

Diagnostic labels or clinical assessments outside your scope of practice
Interpreting why the person felt a certain way without them saying so
Vague phrases like 'good session' or 'seemed better' without observable detail
Omitting risk status entirely — always note whether concerns were present or absent

When this may need escalation

Recovery coaching is non-clinical, but there are situations that require you to follow your provider's risk and escalation process immediately.

Any disclosure of thoughts of self-harm or harm to others — follow your provider's risk process and escalate to clinical support or emergency services as required
Significant or sudden change in behaviour, presentation, or expressed distress that is outside the norm for this person
Any safeguarding concern or disclosure of abuse — report as required by your organisation and relevant legislation

SupportNotes helps you write clearer, more objective drafts. It is not the NDIS, not legal advice, and not a substitute for incident reporting. You remain responsible for accuracy and for lodging any reportable incident with the NDIS Quality & Safeguards Commission.

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FAQ

Can a recovery coach or mental health support worker write clinical notes?: No — recovery coaches and mental health support workers write support notes, not clinical notes. Your note should record what was discussed, how the person engaged, and agreed actions. It should not include diagnoses, clinical assessments, or interpretations that fall outside your scope of practice. If you have clinical concerns, escalate to the appropriate clinician.
How should I describe a person's mood in a support note?: Use observable, objective language rather than clinical terms or assumptions. For example, 'client reported feeling low' or 'client's speech and engagement were noticeably more animated by the end of the session' is clearer and more accurate than 'client was depressed' or 'client seemed happier'. Describe what you saw or what the person said — not what you think they were feeling.
Do I always need to record risk in a mental health support note?: Yes. A good mental health support note always includes a brief risk statement, even if there were no concerns — for example, 'no risk concerns were raised or observed during this session'. This protects you and supports any clinician who reviews the notes later. If a risk concern was raised or observed, record what happened and what action you took, and escalate according to your provider's process.