How to Document Psychedelic-Assisted and Ketamine Therapy Sessions

A practical guide for therapists and clinicians working in ketamine-assisted, MDMA-assisted, and psilocybin-assisted therapy settings. Covers preparation documentation, dosing session notes, integration sessions, informed consent specifics, adverse event reporting, and regulatory compliance requirements.

Why Psychedelic-Assisted Therapy Documentation Is Its Own Category

Standard therapy documentation assumes a consistent cognitive state for the client throughout the session. You present, they engage verbally, you observe, you intervene, you document. That assumption breaks entirely in psychedelic-assisted therapy (PAT).

In ketamine-assisted therapy (KAT), MDMA-assisted therapy, and psilocybin-assisted therapy, clients spend a significant portion of the session in an altered state of consciousness: non-ordinary perceptual experiences, reduced ego boundaries, atypical affect, and diminished capacity for standard verbal reporting. The clinician's role shifts from traditional talk therapy toward holding, witnessing, and guiding an internal process the client cannot fully articulate in the moment.

This creates documentation challenges that no standard SOAP note template was designed to handle.

At the same time, PAT exists in one of the most closely watched regulatory environments in mental health. Ketamine is a Schedule III controlled substance. MDMA and psilocybin are currently Schedule I substances, accessible in clinical settings only through FDA Breakthrough Therapy designation and IRB-approved protocols. State-level regulations vary, and the legal landscape is evolving quickly. What you document, how completely you document it, and how carefully you handle adverse event reporting can have professional and legal consequences.

This guide gives clinicians working in these settings a practical, thorough framework for documentation at every stage of treatment.

The Three-Phase Treatment Arc and What Each Phase Requires

Psychedelic-assisted therapy is not a single session. It is a structured multi-phase process with distinct documentation demands at each stage.

Phase 1: Preparation Sessions

Preparation sessions are standard talk therapy sessions conducted before any dosing begins. Their purpose is clinical assessment, therapeutic relationship building, psychoeducation, and explicit informed consent. From a documentation standpoint, preparation notes are the most heavily scrutinized part of the chart because they establish medical necessity and legal protection for what follows.

What to document in every preparation session:

Presenting diagnosis and treatment rationale: why is PAT the appropriate treatment for this client, at this time, over other available modalities?
Psychiatric and medical history relevant to the substance being used (for ketamine: cardiovascular history, dissociative disorder history, current medications, history of mania; for psilocybin: personal or family history of psychosis; for MDMA: cardiac conditions, SSRI use, history of serotonin syndrome)
Baseline mental status examination findings
Psychoeducation provided and client's understanding of it: what the dosing experience will involve, likely perceptual changes, potential for difficult material to arise
The client's stated intentions for the experience: in most protocols, clients articulate specific therapeutic goals before dosing
Safety planning: what the client will do if distressing material persists after the session, emergency contact plans, transportation to and from dosing sessions
Therapist clinical rationale for proceeding to dosing

A fictional example: "Marcus, 44, presents with treatment-resistant major depressive disorder following two failed antidepressant trials and one course of CBT. KAT is being offered through clinic's ketamine program following psychiatric clearance on 03-15-2026. Preparation session 2 of 3 conducted today. Reviewed dissociative effects and set/setting concepts in detail. Marcus articulated intentions: 'understand why I've felt numb since my father died.' No history of mania, psychosis, or active suicidality. Transportation confirmed with spouse. Medical clearance on file."

Phase 2: Dosing Sessions

The dosing session note is the hardest to write and the most important to get right. The client has limited capacity for verbal reporting during the altered state. Much of what is clinically significant is behavioral, physiological, and qualitative rather than conversational. And you, as the therapist, are actively present and attending throughout, which leaves little room for detailed real-time note-taking.

Most experienced PAT clinicians use a structured observation template during the session and write a retrospective note immediately after the client's recovery period, before they leave the office.

What to document in every dosing session:

Substance administered, dose, route of administration, and time of administration
Vital signs at baseline, mid-session, and post-session (particularly for ketamine and MDMA)
Set and setting conditions: client's stated emotional state before dosing, the clinical environment setup (music, eye shades, positioning), who was present
Onset time and general character of the altered state: Did the client engage quickly? Was there early resistance or anxiety? What was the quality of the experience (introspective, visual, somatic, emotionally intense)?
Observable behavioral markers during the session: body movements, facial expressions, spontaneous vocalizations, emotional releases (crying, laughter), signs of distress
Any breakthrough anxiety or difficult periods and how they were managed (therapist verbal reassurance, physical grounding, breathing guidance)
Duration of altered state and return to baseline: document when the client was oriented, calm, and able to engage in conversation
Client's immediate verbal report after return to baseline: first impressions of the experience before formal integration begins
Any adverse events (see adverse event reporting section below)
Post-session monitoring period before discharge: how long, vital signs at discharge, client's functional state at discharge, confirmed safe transportation

A fictional example: "Dosing session 1 of 2. Ketamine 0.5 mg/kg IV administered by Dr. Soto at 10:14 AM. Pre-dosing vitals: BP 118/76, HR 72. Client presented with mild anticipatory anxiety before onset (reported 4/10 anxiety). Onset approximately 8 minutes post-infusion. Altered state characterized by sustained stillness, occasional slow breathing changes, and two brief periods of visible emotional release (tearing, approximately 10:45 and 11:10). No signs of agitation, cardiovascular distress, or emergency intervention needed. Client returned to conversational orientation at 11:42 AM. Immediate report: 'I saw my father. I told him things I never said. I feel heavy but it was important.' Vitals at 11:50 AM: BP 122/78, HR 74. Discharged to spouse at 12:20 PM in stable condition."

Phase 3: Integration Sessions

Integration sessions are where the therapeutic work of PAT is consolidated. Many clinicians find these the most familiar to document because they resemble standard psychotherapy notes. But they have their own specific elements that distinguish them from generic therapy documentation.

What to document in every integration session:

Time elapsed since most recent dosing session
Client's account of the dosing experience as it has settled and evolved since the session
Emotional, cognitive, and behavioral shifts observed since dosing: Has anything changed in mood, sleep, perspective, relationships, or symptoms?
Specific material that arose during the dosing session and how the client is making meaning of it
Therapeutic interventions applied during integration (narrative processing, somatic awareness, journaling review, parts work, etc.)
Connection between the dosing experience and the client's stated treatment goals from the preparation phase
Safety screening: current suicidality, any emergence of destabilizing material since the dosing session
Plan for the next session or dosing cycle

A fictional example: "Integration session 3, 14 days post-dosing session 1. Marcus reports significant reduction in anhedonia since ketamine session: 'I've actually wanted to cook again.' Sleep improved from 4 to 6 hours with fewer early awakenings. Session focused on narrative processing of material that arose during dosing (relationship with his late father, unresolved grief). Marcus connected his emotional numbness to a pattern of suppressing grief that predated his father's death. Assigned reflective journaling on this theme before next session. PHQ-9 score today: 11, down from 18 at intake. Plan: integration session 4 in two weeks, then reassess for second dosing cycle."

Informed consent in PAT is more complex than in standard outpatient therapy, and "I have consent on file" is not sufficient documentation. Specific elements must be documented explicitly.

What informed consent documentation must include for PAT:

The specific substance, dose range, and method of administration
Known risks, including cardiovascular effects (ketamine, MDMA), potential for psychological distress, transient dissociation, and the possibility that distressing memories or emotions may emerge
The experimental or protocol-based nature of the treatment, including any IRB approvals or Expanded Access designations
Client's right to withdraw from the protocol at any stage
Confidentiality limits specific to the setting (research protocols have their own reporting requirements)
Specific acknowledgment of the altered state: that the client will have reduced capacity for consent during the dosing session itself, and that their advance consent covers this period
For MDMA and psilocybin protocols: explicit acknowledgment of the Schedule I status and the legal framework under which the substance is being administered
Therapist credentials and training in PAT specifically
Date the consent was reviewed, discussed, and signed

Document a brief note each time consent is revisited during preparation: "Informed consent reviewed in today's session. Client confirmed understanding of dissociative effects, cardiovascular monitoring requirements, and the protocol's research-based status. No new questions. Consent form on file."

Adverse Event Reporting

Adverse event documentation in PAT must be thorough, time-stamped, and include your clinical response. Common adverse events range from mild (nausea, brief dissociative confusion, transient anxiety) to serious (cardiovascular instability, prolonged dissociation, emergence of suicidal ideation post-session).

For any adverse event, document:

The event itself: observable symptoms, client's self-report, onset time and duration
Severity classification: mild, moderate, or severe; whether it required intervention
Clinical response: what you did, in what order, and the outcome
Whether the event was expected based on the substance's known profile or unexpected
Whether the event was reported to the supervising physician, clinic medical director, or IRB (for research protocols)
Client's status at discharge and any follow-up plan

For research and Expanded Access protocols, adverse event reporting to the IRB and sponsor often has formal timelines (serious adverse events within 24 to 72 hours). Know your protocol's requirements and document that you met them.

SOAP and DAP Formats Adapted for PAT

Standard note formats can accommodate PAT documentation with deliberate modifications.

SOAP Note for a Dosing Session

S (Subjective): Pre-dosing client report (mood, anxiety level, intention for the session, any physical symptoms). Post-dosing client's immediate verbal report of the experience.

O (Objective): Substance administered, dose, route, time. Vital signs at key intervals. Observable behavioral observations during the altered state period. Duration of altered state. Any adverse events with your clinical response.

A (Assessment): Clinical interpretation of the session: depth of engagement, material that emerged, any concerns. Connection to treatment goals. Safety assessment post-session.

P (Plan): Post-dosing monitoring and discharge details. Integration session schedule. Any medication or safety follow-up. Whether a second dosing session is planned and on what timeline.

DAP Note for an Integration Session

D (Data): Client's account of how the dosing experience has settled. Behavioral and mood changes reported since dosing. Specific themes or memories that have remained salient. Current symptom ratings.

A (Assessment): Therapist's clinical analysis of the integration process. Is the client metabolizing the experience productively? Are there signs of destabilization? How does the material connect to original treatment goals?

P (Plan): Therapeutic interventions applied, homework or reflective exercises assigned, next session goals, plan for next dosing cycle if applicable.

Regulatory Compliance: What Differs from Standard Therapy Notes

The regulatory context for PAT notes differs from standard outpatient therapy in several important ways.

For ketamine, documentation requirements follow controlled substance regulations. Depending on your jurisdiction and clinic structure, this may mean a separate controlled substance log, a physician's order on file for each dose, and requirements to document screening for substance misuse. Ketamine administered by infusion clinics with embedded therapists involves a different documentation split than ketamine prescribed as a lozenge or troche with a separate therapist.

For MDMA and psilocybin under FDA protocols, you are operating within a formal research framework. That means an IRB-approved protocol governs what you document, how it is stored, and how it is reported. Your clinical notes are also research records. The standard for completeness is higher than typical outpatient therapy.

For state-regulated psilocybin programs (Oregon and Colorado as of 2026), the licensing and documentation requirements are set by state agencies, not the FDA. Know the specific requirements for your state's facilitator license and service center license. These programs often require documentation of a preparation session, the facilitated session, and an integration session with specific elements in each.

Regardless of the framework, keep clinical notes and consent documents for longer than standard retention periods. PAT is new enough that legal and regulatory questions are likely to arise years after treatment concludes.

Common Documentation Mistakes in PAT Settings

Writing the dosing note from memory the next day. Altered state sessions are unusually memorable for the therapist, but details blur and the sequence of events compresses. Write the note immediately after the client leaves, while the timeline and specific observations are fresh.

Using generic language for the altered state. "Client appeared to be in an altered state" tells no one anything useful. Document behavioral specifics: posture, movement, verbalization, emotional expression, apparent depth of processing.

Treating preparation session notes as standard intake notes. Preparation notes need to establish your clinical rationale for PAT specifically, not just document presenting problems.

Omitting vital signs or documenting them without timestamps. In a medico-legal review of an adverse event, timestamped vitals are the difference between demonstrable safety monitoring and a question about whether you checked at all.

Under-documenting integration. Many clinicians write thorough dosing notes and thin integration notes. The integration sessions are where the clinical outcomes are built. They deserve the same attention.

Not documenting what you said during a difficult moment. If a client became acutely distressed and you used grounding techniques or made a clinical decision to redirect them, that needs to be in the note. Your clinical reasoning during the session is part of the record.

Tools That Help

Structured note templates reduce the cognitive load of remembering every required element when you are writing post-session. A template built for PAT will prompt you for dosing specifics, vital sign entries, adverse event documentation, and integration themes all in a single workflow.

If you use a tool like NotuDocs, you can build a PAT-specific template that matches your clinic's documentation requirements and your preferred note format. That means you are not adapting a generic SOAP note every time; the structure is already there and you fill in what happened in that session specifically.