Documenting Text Messages and Emails

“Do I need to copy and paste all emails from clients into their file?”

“How do I document or save text messages with clients?”

These are concerns that usually come up for mental health therapists after they start seeing clients, and after they’ve reviewed policies and procedures with them. It’s okay though, even if your client starts texting you out of the blue and you had no policy around this, you have plenty of options for documenting this conversation… easily and simply.

Let’s review some tips for documenting text messages and emails with your counseling clients:

Think of texts and emails like voicemail.

Remember when all you did was talk on the phone? Life was so much simpler then… in some ways.

The problem is that we often over-complicate things when they are new, and texting or emailing with clients is still relatively new in the world of mental health.

But when you think about it, texts and emails are commonly replacing communication that would have happened over the phone 20 years ago… so a good question to ask yourself is, “What would I do if this were a voicemail?”

You’d likely write a brief note about the interaction. For example, you might write something like:

“Client left voicemail cancelling session due to being sick. I called her back and she will attend next session on xx/yy/zz.”

That’s it! Easy!!

Same thing with a text or email communicating the same type of information. Simply write a brief note in the file so you remember what happened and it’s documented for good.

Summarize, summarize, summarize

I really don’t believe it’s necessary to copy and paste most emails or text messages with clients. The key is to make sure you do have the communication documented in some way, and the easiest way to do this is to summarize in a brief note, like the example above.

Don’t overwhelm yourself!

Tracking and copying all this information may be unrealistic but it doesn’t mean you’re being unethical or not able to document the important aspect of the communication.

And if you prefer to have ALL the back and forth communication with your clients, there are actually some cool apps available that will save this information for you. They offer a secure way to text with clients and the ability to print out or review any text messages.

The added benefit of email and text communication with your therapy clients is that, when needed, you actually can copy and paste the entire communication.

While I don’t recommend doing this every time, it can be very helpful when ethical dilemmas arise or when there is confusion about the communication.

So, in my opinion, these types of communication can actually be more useful than voicemails! It is unlikely you’d want to save a full voicemail from a client, but copying and pasting a long email into your EHR takes about 30 seconds… and gives you a secure way to save potentially important communication.

Let us know in the comments below:

Do you save all your emails or text messages with clients? Do you use an app to communicate with clients and save all the data?

Remember, there’s no right or wrong answer here and we can all help one another by sharing.

Writing Court Letters in Private Practice

There are few things that stress out therapists as much as dealing with a subpoena or a request for records. Most of us prefer to avoid anything court-related at all costs.

However, many counselors unknowingly get involved with court cases through one simple step: Writing a letter that is used in a court case.

While a letter is often preferable to releasing all the psychotherapy records, it’s important to remember that letters can also have significance and we should be careful about what we write. We also need to make sure we review the potential consequences of letters with our clients.

You might be thinking, “What can be so harmful about writing a simple letter?”

Well, it is not so much the letter itself, but the potential for blurring lines of competence that can get therapists into trouble.

Let’s review a common scenario for writing a court letter…


We'll call our imaginary therapist in this scenario "Mary Muggle, LMFT." Mary has been seeing children and adolescents in a private practice setting for about 10 years and has been licensed for about 12 years.

>> It's important to note here that experienced clinicians appear to be more at risk in these areas. During extensive research into common board violations among various practitioners, I found very few examples of newer therapists making a violation. 

Mary begins seeing a 10-year-old boy we'll call Dudley. Dudley's parents are going through a divorce and over the last two months his grades have been dropping and he started getting in fights at school. His mother brings him to treatment and explains that Dudley's father travels frequently for work and is aware that Dudley will be getting counseling but doesn't want to be involved.

Mary asks for custody paperwork and Dudley's mother brings in a form that isn't very clear but it appears that the parents have equal custody for now. Mary files this with her records and begins seeing Dudley for weekly therapy. She does leave a voicemail for Dudley's father to see if he can come in for an appointment but she never hears back.

During his sessions Dudley often reports missing his father because he sees him very irregularly now that his parents are no longer living together. He reports visits with his father being sporadic and including lots of take-out or junk food and very little discipline or structure. His father also does not seem to approve of Dudley being in therapy and says things like, "Fighting isn't a problem. Not sticking up for yourself is a problem. Don't let them turn you into a pansy."

After about three months of weekly sessions Dudley has made some improvement in school and seems to enjoy his weekly sessions but admits to Mary that he feels embarrassed to talk about them with his father.

It is around this time that Dudley's mother asks Mary to write a letter for an upcoming court date.

She is worried that Dudley's father will ask for therapy to be discontinued. She also confides that she is concerned his father will request more time with Dudley now that he is done with the work project that required so much travel. 

Mary writes a letter summarizing Dudley's reason for referral, his goals and progress to date, as well as Dudley’s concerns about his father not supporting the therapy process. She highlights in the letter that this can be detrimental to therapeutic rapport, Dudley's ongoing progress in school, and she reports that Dudley's father has been uninvolved and may be a negative influence. She also recommends Dudley's mother remain the primary caregiver.


Writing a letter about Dudley's treatment is perfectly acceptable, but Mary makes two critical mistakes in this scenario:

  1. She provides an opinion about Dudley's father without ever talking to Dudley's father.

  2. She provides a recommendation related to custody without being appointed (or even trained) to do so.

These mistakes are critical errors because Mary is practicing outside her scope of practice and has a potentially harmful dual relationship.

Let’s dig into each of these issues…

The Ethics of Dual Relationships and Scope of Practice

As mental health professionals, we often see into the very vulnerable parts of individuals and families. We also form a connection with our clients. We like to use the term “therapeutic rapport” to sound more academic but it is often a basic, human connection we have with our clients.

This connection is important for counseling to provide a healing environment where clients can be vulnerable. However, this connection impairs our ability to be objective.

That is why, for example, it is usually unethical for me as a psychologist to do psychological testing with someone who is also a therapy client. Or to test someone whom I already know well.

No matter how objective psychological tests are, my interpretation or evaluation report is very likely to be influenced by my prior knowledge of the person’s abilities, history, etc.

Likewise, our relationship with our clients can impair our ability to objectively look at other situations, such as custody agreements. This applies when your client is the child, as well as when your client is one of the parents.

Custody situations are often very emotionally charged for all involved and this makes objectivity that much harder.

So it is generally considered unethical to provide an opinion about custody unless you are specifically trained in providing such assessments (which often have very specific legal guidelines and ramifications) and have no prior relationship with members of the family involved.

Are there exceptions to these guidelines? Always!

For example, if you live in a rural area and there are very few providers, you might be the only person available to provide such an assessment, despite some type of prior relationship with the family involved.

This is where we must consult our ethical guidelines, consult with colleagues who can offer guidance, and disclose all the potential things that might be impacting our objectivity.

So what do we do about writing court letters?

Keep writing them!

(Or don’t… more on that in a minute)

Yes, keep writing them but always keep in mind that letters can have a significant impact and…

It is not your role as the therapist to make legal determinations for your clients.

>> Should your client be excused from work because of the significant stress it is causing? Your role is to assist the client through this process and potentially, provide a letter explaining their current symptoms and stressors.

>> Should your client receive social security disability because of their diagnosis? Your role is (usually) to report the symptoms, history of these symptoms, impact of the diagnosis, and the prognosis based on your ongoing professional assessment.

>> Should your client who loves his children have custody of them because their mother (his ex-wife) is an alcoholic and currently in jail? Your role is to simply report your client’s progress in treatment, regardless of the circumstances.

Most counselors are well-meaning and genuinely think the recommendations they include in letters will benefit their clients, and the others involved.

We became mental health professionals because we want to help people! And it often seems unfair when we can’t help our clients the way we want.

However, you can help your clients when they are experiencing any of the above scenarios.

Here are some general guidelines for writing letters that might be requested by an attorney, sent to an evaluator, or used to determine a client’s role or benefits in some way:

  • Discuss with your client the limitations and potential ramifications of writing such a letter and that you cannot guarantee any type of result, positive or negative.

  • Stick to the facts. All of your statements should be backed by data (whether that’s your own clinical assessment, reports by others, observation, etc.).

  • Report on what is observable and provide examples or quotes, if needed. Keep in mind that your client’s statements about the situation or anything you have observed might be relevant here.

  • Keep your opinions about anyone or anything that is not your client out of the letter. For example, Mary could certainly write that Dudley’s father has been unresponsive to her attempts to reach out and therefore uninvolved in treatment. Those are facts based on her experience, not an opinion.

  • Keep it simple. Stick with symptoms and/or reason for referral, progress to date, and perhaps, prognosis for treatment.

  • Don’t be afraid to say no or to charge for your time. Writing letters is stressful and it does take time, but it’s also not required, unless you have a subpoena or some other type of court order. You have every right to say no or to charge a reasonable fee for your time. Just make sure this is outlined in your policies!

Keep in mind these guidelines are generalized and you must always consult your own state laws and professional ethics!

Using these guidelines should help you stay ethical, provide excellent care for your clients, and create a less stressful experience for you as the treating therapist.

How do you handle requests for letters from clients? Let us know in the comments below!

Therapy Interventions Cheat Sheet for Case Notes

You may have heard me mention that I don’t usually recommend treatment planners for notes and other documentation.

That’s because these planners rarely save time. In fact, I hear from many counselors who tell me they actually end up taking more time and definitely create more confusion.

These planners also don’t help you personalize your progress notes. That’s why I created this video!

In this video I not only walk you through the benefits of creating your own cheat sheet, but I’m actually sharing 10 therapy interventions that you can still and add to your cheat sheet right away.

Not into watching a video?

Well, you’ll miss out on the examples of how to implement a lot of these, but I’m listing them here for your convenience!

These are 10 therapy interventions that pretty much ANY mental health counselor needs to have in their writing arsenal:

  1. Assessed

  2. Challenged

  3. Demonstrated

  4. Evaluated

  5. Explored

  6. Identified

  7. Labeled

  8. Normalized

  9. Reflected

  10. Processed

Now tell us!

Do you use a cheat sheet for your notes? Which interventions do you plan to use in your cheat sheet?

Process Notes: What You MUST Know

Maybe you’ve heard some of these terms and are confused about how they are different (or the same!)…

  • Process notes

  • Progress notes

  • Psychotherapy notes

  • Case notes

  • Clinical notes

What do all these terms mean?!

Fear not, amazing therapist, I am clearing this up in the video below!

And in case you’re not into videos, here’s a snap shot of what I cover:

  1. “Psychotherapy notes” and “process notes” are the same thing, we all just tend to use different terms. The term “psychotherapy notes” was created specifically for HIPAA so this impacts how we use this term.

  2. Process notes are totally optional! Yup, there is no requirement to write them, so it’s totally up to you.

  3. Process notes don’t even have to be legible. You can draw, use shorthand and abbreviations. In short, you can do what you want since they are just for you.

But most importantly, process notes are NOT a place to hide important clinical information that may be needed for treatment.

Your progress notes should always document treatment and should be able to stand alone to tell the story of your client’s journey in therapy.

Now, let us know! Do you use process notes? Why or why not?

Credit Card Fees and Private Practice: Can I Pass the Fee to My Client?

Credit cards are pretty standard practice in the world of mental health these days. And, in my opinion, that’s a good thing.

Credit cards mean it’s easier for clients to pay for services, you can be assured that you’ll be paid, and clients can often use Flexible Spending Accounts to save money and pay for therapy.

However, credit card processing is NOT free so someone has to pay for these companies to create massive firewalls and protect our client’s personal data… but who pays?

In this video I explain you shouldn’t pass the fee on to your clients… but I also explain how to do this without losing money yourself.

Because yes, having a modern therapy practice does cost a bit more these days, but it’s totally worth it.

I mentioned IvyPay in the video and yes, if you click on the link below you’ll get $1,000 free in initial credit card fees! Yay, thanks, IvyPay!

Click here to check it out.

You can learn more about all the things to consider with credit cards by checking out this blog post on Credit Cards: Your Questions Answered.

Let us know in the comments below! Do you factor in credit card fees when creating your own fee for counseling services?

How To Catch Up On Notes

One of the most common concerns I hear from therapists is that they are having trouble staying on top of their notes.

This is a big concern and the problem can get out of hand very quickly. 

That's why my approach to helping counselors catch up on progress notes consists of two things:

1. Create a sustainable strategy for staying on top of current notes.

2. Create a realistic plan for catching up on older notes.

Once these two things are mastered, you're good to go! The hard part is getting there...

That's why I recorded the following videos with steps on each strategy.

One caveat: It is tempting to jump to the catch up plan because that may be the immediate need that is causing stress. Don't do this!

It is sooooo important to create a sustainable schedule for yourself first so that we break the cycle of falling behind. So, make sure you watch Part 1 and really focus on trying out this strategy for a week or two before you jump to Part 2.

How To Catch Up On Notes (Part 1)

Create a sustainable schedule for ongoing notes

 

How To Catch Up On Notes (Part 2)

Create your catch up plan

Do you want extra support to get some notes done ASAP?

Click here to sign up for the Summer Paperwork Blitz!

More of My Favorite Intake Assessment Questions

You may have already read about My 4 Favorite Assessment Questions but let's get into some more! In this video I'm sharing four more questions I recommend you ask your clients during the intake process.

These questions will help you get the necessary historical data to treat them best but also help you make a connection more easily.

Still have questions about the intake assessment process? Then check out this blog post on Assessment Dilemmas and FAQ's to get some tips on how to simplify the process. 

Let us know in the comments below what your favorite questions are to build rapport with clients and get the information you need to provide them the best therapy possible. 

What is the BEST Case Note Template?

There are many different progress note templates to choose from and I often find that people are using a template they don't like... so what do I recommend? Well, that depends on you!

The Bad News: The best note template will vary with each clinician.

The Good News: The best note template will vary with each clinician... so you can make some quick changes right now that will improve your notes!

Watch the video below or read the summary underneath for some details on how you can do this today.

Here are some quick things to consider before adjusting your template:

  1. What sections of my note do I like?
  2. What sections seem insufficient?
  3. What do I write that doesn't seem to fit in one of my current template sections?

Then look at ways you can easily make adjustments to just these sections. You don't need to change the whole template! Add a section, take a section away, etc. Do what works for you.

Next, add checkboxes... but do it carefully and thoughtfully.

For the interventions section:

Don't go off someone else's list. Sure, you might use a list to gather ideas but don't include every possible intervention. If you're ignoring something all the time it is just getting in your way- delete it and move on!

For your client's response section:

Particularly if you work with similar types of clients, you will often have similar responses over time. Again, if these come up often then create checkboxes. If not, you can ignore this part... do what works for you ;) 

For the plan section:

You likely have common recommendations for your clients so why not create checkboxes that will make your life easier? You can always leave blank spaces to provide more detail on things like dates or specific recommendations.

Want to see some examples?

Click here to sign up for the FREE Private Practice Paperwork Crash Course and you'll get immediate access to video trainings, templates and note examples.

What is Medical Necessity?

Medical necessity is a term that is based on the medical model of treatment but is also applied to mental health treatment. Sometimes that can be confusing for those of us who are counselors, therapists, social workers and psychologists!

In this video I explain:

  • The three main components of medical necessity 
  • Why insurance companies use medical necessity for mental health
  • Where you want to highlight medical necessity in your documentation

Click here to submit a question for a future live Q&A video!

And let us know what you think in the comments below. Are there other strategies you use to talk with insurance companies? Does this seem to cover what is needed for your client notes?

Quick Clinical Case Notes (Collaborative Documentation Q&A)

Recently I've been getting a lot of questions about a somewhat controversial topic- collaborative documentation.  While I don't think everyone should use this strategy, I definitely think it's worth considering. 

Collaborative documentation (sometimes called concurrent documentation) can actually look very different for different therapists!

In this video I review four ways you can incorporate this strategy in your counseling practice right now:

  • Writing notes with clients in session
  • Writing part of the note with clients during session
  • Sharing notes with clients after they are written
  • Having clients complete intake paperwork before the initial session

I also go through some of the benefits and potential drawbacks of this technique:

  • Less time writing notes (the most obvious benefit!)
  • Increased communication and connection with your clients
  • Reduction of errors in documentation
  • Better engagement of "resistant" clients

If you’d like to submit a question for me to answer on a future YouTube Live Q&A, then click here.

>> Subscribe to my YouTube channel and click the bell for notifications so you don’t miss the next Live Q&A! 

I'm on every Monday at 12pm Pacific Time.

If you’re still looking for help with your documentation, click here to check out the FREE Private Practice Paperwork Crash Course

Do Therapists Really Get Disciplined for Failing to Take Notes?

One of the biggest concerns I hear from counselors about their documentation is whether or not their notes will be read by someone else. Usually they are most concerned by a potential court case Their concern is that the notes will somehow harm their client in this case.

Click here to read about whether or not I think limiting your note content can help you or your clients with court cases.

Secondly, the concern is about others reading their notes and that they will be deemed an incompetent or negligent clinician when the notes are revealed. 

Why are so many therapists worried about their notes somehow revealing poor practices? 

I find that the lack of clarity about what to write in therapy notes contributes to a LOT of worry. That worry builds when counselors seek out information about how to write progress notes and they find a myriad of conflicting information from seemingly reliable sources. 

The worry grows exponentially when that same counselor falls behind in their notes and needs to catch up on paperwork

Then you add to that a horror story of another counselor being put on probation or losing a contract due to poor note writing and this becomes a real concern!

But is it true that psychotherapists get disciplined for poor record keeping? Does this really happen?

Yes!

I find this commonly happens when some other catalyst creates a client complaint or Board investigation.

When the Board begins to investigate and requests records, they often find two additional problems (other than the original complaint):

  1. The clinician failed to obtain proper informed consent.

  2. The clinician failed to maintain adequate records.

Keep in mind that these common scenarios are regardless of whether or not the therapist is actually found to be at fault regarding the original complaint. 

So, let's dive in to each of these two scenarios and see how to avoid these common issues...

The clinician failed to obtain proper informed consent.

1) This often occurs when therapists are providing services to children and adolescents. The therapist may fail to inform the parents when it is required or may fail to obtain consent from the correct party (or both parties, if required). Similarly, this can also happen when a dependent adult is being treated.

2) I've also seen cases of this when a psychologist failed to obtain proper consent for psychological testing or did not adequately document reviewing the differences between a testing and a therapeutic counseling relationship. 

3) There are also scenarios where the therapist does not actually review the informed consent process at the beginning of therapy. Instead, they simply make sure forms are signed and don't review any policies or procedures, potential limits to confidentiality, or describe the therapeutic process.

When counselors are too lax about the intake process and jump right in to the therapy process they set themselves and their clients up for a potential disaster and significant harm to therapeutic rapport.   

4) Lastly, the counselor may simply fail to document that they obtained consent for treatment. I always recommend you document in an intake note that you reviewed necessary policies, potential limits to confidentiality and obtained consent for treatment.

The clinician failed to maintain adequate records.

1) One common problem here is that the therapist simply has incomplete records. They may be missing case notes, informed consent documents or other necessary paperwork, such as releases of information.

2) Another common problem is that the therapist has case notes but no other supporting documentation, such as a treatment plan or intake paperwork.

3) Lastly, the issue might be around quality of documentation. For example, the counselor only includes such brief information in their case notes that the Board cannot adequately determine if their actions are justified. Or the counselor may fail to document things like important phone calls or missed appointments that corroborate their side of the story. 

>> It's important to note here that experienced clinicians appear to be more at risk in these areas. I found very few examples of newer therapists being disciplined for these concerns. 

What can you do to avoid these potential problems?

Two ongoing things are critical for every licensed psychotherapist in every discipline, state and country:

So, just reading this blog post you are already on the right track! You're making ongoing learning a priority for your career. 

And despite the fact that you may hear different opinions about documentation practices, regularly discussing these practices with other clinicians, along with educating yourself on best practices, will help you gain the critical thinking needed to decide for yourself what you will do in your practice. 

If you're looking for a community of other therapists with whom you can consult, as well as a place to obtain continuing education credits and learn about individualized documentation techniques, then click here check out the Meaningful Documentation Academy

The Academy incorporates community and education to make sure you are prepared and confident about all things documentation.

How to Review Notes by Other Therapists

If you're a supervisor then you know it can feel like a daunting task to sit down and review notes for other therapists. 

Or maybe you've tried to do this for your own notes and found that you're not sure where to start, what to look for, or how to use the feedback you obtain.

Well, this quick video will help alleviate that confusion! 

I'm going to share with you how to structure your review and provide some tips so that you can make it a meaningful experience for yourself and your supervisee. 

And if you're looking for a simple tool you can use to make sure notes have all their necessary components, click below to sign up for my weekly emails and you'll also receive a Notes Checklist.

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Better, Faster Treatment Plans

Treatment plans are the number one thing people search on Google to find QA Prep! That tells me there are LOTS of questions from mental health therapists about this topic.

In this quick video I'm sharing with you one easy way you can improve the quality of your treatment plans while also saving yourself time.

Not too keen on watching a video? Then read the highlights below!

I'm not quite sure why treatment planning turned into something we have to do for paperwork's sake instead of something we do for a real purpose. But unfortunately, it did. And I hope to change that. 

One easy way to make your treatment plans more meaningful to you and your clients is to write the treatment plan with the client in the room.

I know, I know... a lot of clinicians don't like to do this! They're worried that doing paperwork with a client will negatively impact the relationship and create a barrier. However, when done with care, it actually has a different impact. 

Here are some benefits of writing treatment plans with clients:

  • You'll be able to use your client's own words to describe their concerns, needs and goals
  • You're able to receive immediate feedback on what they want out of therapy or how they view the counseling process
  • You can share with them what your involvement is in the therapeutic process

So, if you've never tried doing this before and treatment plans are a hassle for you, try it out! Let us know what you think in the comments below.

Productivity Hack for Writing Case Notes

I've got a quick tip for you that can dramatically improve your productivity when writing case notes and catching up on paperwork!

In this video I share with you the Pomodoro Technique, a popular time management strategy for getting tasks done.

The key to the Pomodoro Technique is taking breaks! Do NOT skip this part and when you're trying it out make sure you stick to the schedule. 

This is one of the strategies we use for the weekly Get Notes Done Hour in the Meaningful Documentation Academy, as well as our quarterly Get Notes Done Days... and people are really liking it!

Let me know how this strategy works for you in the comments below.

Step-by-Step Intake Progress Note

Did you know that your very first progress note should look different from your other client case notes? 

That's because the first session with clients, the intake assessment, is very different from our "typical" sessions... whatever "typical" looks like to you ;) 

In that first session with mental health clients we have forms to review and information to gather. And there are very important things to discuss with our clients so they understand the counseling process.

I recommend including that you reviewed all of these things in every intake progress note you complete (obviously, with the understand that you actually did review those things with the client in session):

  • Limits to confidentiality
  • Potential benefits and drawbacks to treatment
  • Consent for treatment
  • Attendance policy
  • Communication outside of session
  • Reason for seeking treatment
  • Assessment of symptoms
  • Assessment of biopsychosocial data
  • Plan for treatment

Some sections may have more or less detail, depending on the client's situation or length of the session.

For example, it often takes more time to do an intake for child and adolescent clients because we want to get information from the caretakers, as well as the client. Others simply do a more in-depth assessment and take 2-4 sessions. 

When that happens, simply document the portions you did cover (and with whom you discussed it) and then what you plan to cover in the next session. However, I do recommend that you review limits to confidentiality and obtain consent at the first session, whenever possible.

Want to see an example note?

I've got one for you! Check out this sample note below to see how it looks when we put it all together. I'm using the DAP note format here...

Data: 

Client arrived early and had completed intake paperwork online using client portal. Reviewed with client the limits to confidentiality, potential benefits and drawbacks of treatment, communication outside of session and attendance policies. Obtained consent for treatment. Discussed biopsychosocial history further and completed all intake paperwork. Assessed reason for treatment, current struggles and symptoms. Identified goals for treatment. Current goals include 1) Creating a routine for relaxation and self-care and 2) Identifying priorities and planning for work and home tasks accordingly. Client requested weekly assignments to stay on task so we will use this format to start and evaluate after 6-8 weeks. 

Assessment:

Client was comfortable disclosing details about prior treatment and mental health history. Exhibits excellent insight and desire for continued personal growth but is frustrated with ongoing struggles and feels she is not meeting her potential. Previously treated for both depression and anxiety, for which she has created excellent coping strategies and continues to use cognitive-behavioral techniques to address. Currently struggling with symptoms related to ADHD as primary concern.

Plan: 

Client will attend weekly sessions in the office, with the option to move to online sessions if needed. Therapist will assist client in identifying the appropriate weekly “homework” tasks before the end of each session. Client will provide one check-in via journaling in client portal once per week outside of sessions. Weekly assignment is to gather all to do lists and pending tasks to bring in for next session and label with priority level. Next session scheduled for 05/19/17 at 12pm.

You're probably thinking, "Does my note need to be that detailed?"

Maybe not... that all depends on the situation, as well as how in-depth your intake assessment is. For example, if you don't use homework or if you didn't have time to review treatment goals, this note would be a lot shorter.

On the flip side, if you had to do an assessment of safety because the client reported feeling suicidal, your note might actually be longer

Notice that this note doesn't include anything I would have in my intake assessment form.

That's because I see no reason to write the same thing multiple times!

This used to drive me crazy when I worked in an agency. And it's a reason that soooo many therapists resent paperwork and fall behind. That's why I recommend you streamline your documentation as much as possible. 

If you have questions about substance abuse, past treatment, relationships, and suicidal ideation then why do you need to write these things over again in your intake note? My opinion is that you don't need to duplicate this... but you do need to have it documented somewhere that makes sense.

So, if you miss something on your intake assessment form then write it in your intake progress note and vice versa. 

I've got a checklist you can download to create your own intake note template or to use as a reminder when writing your intake notes.

Enter your info below to sign up for my weekly emails and then check your inbox to download the checklist! Remember to check your spam or junk folder.

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Should I Use a Treatment Planner for My Notes?

I see a LOT of questions in Facebook groups about using treatment planners for writing therapy notes...

  • Which treatment planner is the most helpful?
  • Will a treatment planner make writing notes faster?
  • How can I use a treatment planner with my electronic health record (EHR)?
  • Will using a treatment planner help me avoid an insurance audit?

But I notice that people are asking a lot of questions without explaining what they really want to know. After fours years of answering questions about writing notes in private practice, I know what these counselors are really thinking. 

And what most therapists really want to know is this:

What tool can I use to make writing notes something I will no longer dread, be confused about, or spend hours of my time doing (or avoiding)?

The answer to that question is not something most therapists are happy to hear. Because there isn't just one tool or strategy that will solve that problem.

However, don't lose hope!

That doesn't mean you can't solve the problem. It just takes a little more effort up front and takes the time of setting up individualized systems that work best for you

When Treatment Planners are Helpful

Treatment and notes planners can be really useful when you have the right mindset about how to use them. Here are some ways they are most helpful:

  • When you're looking for ideas on what to write (for example, when you are experiencing writer's block or starting out with a new method/client)
  • If you need help checking your interventions and treatment plans against insurance requirements, since insurance does want you to clearly connect the treatment to the diagnosis
  • When you're just starting out as a new clinician and don't have much experience to reference
  • If you work in an agency setting where you see a variety of clients and may need to work with multiple diagnoses with which you are not immediately familiar

When Treatment Planners are NOT Helpful

There are also plenty of times that treatment and notes planners are not helpful, despite clinicians trying to use them for this exact purpose. Beware using treatment planners for help with notes in the following circumstances:

  • If you don't treat based on a diagnosis, since most treatment planners are diagnosis-based in their recommendations and ideas
  • If you are looking for interventions and strategies with specific clients, browsing a large treatment planner actually tends to become more overwhelming than helpful (it's counterintuitive, I know!)
  • When you're feeling stuck with a client, because usually you need to discuss this with the client or seek consultation and looking through a treatment planner will rarely give you the insight needed in these situations (here's what I often recommend instead)

Additionally, I find that when treatment planners are helpful it's because the clinician works primarily with one diagnosis and ends up using only the portion of the treatment related to that diagnosis. 

My Top Recommendations

You know I would never leave you without some practical things you can implement right away! So here are my recommendations for how to create your own supplement that can make writing notes more simplified and efficient:

1) Use what you already have.

Rather than buying a book with thousands of options you need to sift through, why not go through your own notes? This is the absolute best way to create a list of interventions and goals that are personalized to you and your clients. 

I go into this process more in depth in this blog post, but in a nutshell all you have to do is spend about an hour reviewing 2-3 client records. Write down the interventions you see most often, the ones that stick out as unique to how you work, and anything else that seems important to you.

Voila! You now have a cheat sheet you can use to create a checklist in your notes template and to help help with writing treatment plans.

Repeat this process for goals/objectives and you'll have another cheat sheet for creating treatment plans (you might have to review more files for this since we use the same goals for many months with the same client). Between those two cheat sheets you'll be able to create very customized treatment plans very efficiently!

2) Have prompts ready. 

One of the easiest things you can do right away is have some note writing prompts next to your computer (or wherever it is that you typically write notes). These questions will help get you in the right mindset to write notes and will help you focus on the things that really matter.

I have a list of note writing prompts available inside my free Private Practice Paperwork Crash Course so that all you have to do is sign up, log in and download your prompts!

3) Set a timer.

Have you ever heard of Parkinson's Law? This states that "work expands so as to fill the time available for its completion."

That means if you give yourself 20 minutes to write a note, it will likely take 20 minutes. And if you give yourself 10 minutes to write that same note, it will likely take 10 minutes! 

This can be anxiety-provoking at first but remember that if you do forget something major, you can always go back and add an addendum to your notes. So it's not the end of the world if you feel like the note is unfinished when the timer goes off.

Over time you'll get better at writing notes more quickly and will feel confident that you know exactly how much time is needed to complete your client paperwork.

4) Get support from colleagues.

I'll bet you didn't know that one of the best ways to feel better about writing notes is to have a colleague read them! Yup, it sounds scary at first but I've found that most therapists are actually doing a pretty good job with their notes. They've just never had someone to tell them this.

Inside the Meaningful Documentation Academy I encourage members to submit notes to me for review. I'll actually read their client note and give them direct feedback. 

But you can even do this yourself. Meet with a trusted colleague and review one another's notes as a quality review. Remove whatever identifying information you can and then spend some time sharing with one another what you liked about the other's notes and what pieces were missing.

Now take some action!

Share in the comments what you plan to do next so your notes can become more efficient, simplified and meaningful to the work you do with clients.

Love Your Paperwork: An Interview with Shane Birkel of the Couples Therapist Couch Podcast

Calling all couples counselors! Did you know there's an awesome podcast talking about strategies and nuances specific to couples counseling? 

Shane Birkel, LMFT is a couples therapist and he started a podcast that dives into everything from EFT and the Gottman method to healing from infidelity and working with specialized populations like first responder couples.

In this episode he and I chat about all things paperwork, including some of the nuances that are specific to couples...

  • Billing insurance for couples therapy
  • What to review during intake so you can avoid confidentiality issues later on
  • Organizing files for couples counseling
  • Catching up on therapy progress notes

We spend some time talking about the ever present struggle to stay caught up on notes and review strategies for catching up on notes and creating a realistic schedule to keep your notes up to date. So check it out, take a simple action after listening and then look for other episodes that might be helpful.

Click here to listen.

What was your greatest takeaway from the episode? Let us know in the comments!

Creating Meaningful Documentation: An Interview with Gordon Brewer of The Practice of Therapy Podcast

Are you a big podcast listener? I certainly am! That's why I get really excited about podcasts that are created for mental health professional and talk about one of my favorite topics- business! 

The Practice of Therapy Podcast with Gordon Brewer is another you can add to your list if you share my love of podcasting and business. Gordon and I originally connected on Twitter and after noticing we seemed to share a lot of the same interests I reached out to him about being on his show.

I didn't know he was already planning to reach out to me so we made an interview happen that week and bam! Documentation tips galore ;)

Here's what we covered in this interview:

  • The #1 concern about paperwork that therapists want to discuss with me
  • A counterintuitive way to catch up on notes when you're falling behind
  • One simple way to reframe your notes so they take up less time
  • How Gordon created a tool (Session Note Helper) to make his own notes easier and then shared it with other clinicians
  • How to make your documentation meaningful to the other clinical work you do
  • Common struggles during the transition from agency work to private practice and my biggest regret from when I made the transition myself

I love podcasts because you can easily learn on the go, so this is a great way to get some tips and encouragement no matter where you are! Gordon was some great insight himself, as well as resources he has created to make notes easier over time. 

Click here to listen to the interview.

Then come back and let us know what you think! Share your favorite strategy in the comments below.

Documenting Criminal Activity: Yes or No?

Have you ever felt unsure about how to document questionable behavior exhibited by your clients? Or unsure about whether or not you should document past criminal activity? Well, you're not alone!

This time we're continuing the FAQ series with a more specific topic- documenting criminal activity and/or questionable behavior of your clients. Although this is a shorter series of questions, I actually do receive these questions pretty often and thought they were important to address in the documentation FAQ series.

So, let's dive in to the questions!

"Documenting crimes committed- Do you? Don't you? How to?"

The short answer is YES. However, there are things to consider when documenting your client's criminal history. 

First, let me explain some reasons why this answer is a clear YES...

  1. CYA (cover your assets). You want to know what type of client you are seeing. There are obviously varying levels of criminal behavior and in some cases this won't impact your treatment or be very significant. However, it can easily become significant. For example, if you share a common waiting room with other therapists and you see adults but they see children, it would be important to know if your client could potentially pose a risk to any other clients in the waiting area.
  2. This is objective information as part of an assessment. A criminal record is one of the most basic and objective pieces of information you can gather. It is public information. It is fairly straightforward (although circumstances can certainly make a huge difference) and it is likely relevant to your client's psychosocial history.
  3. It is clinically relevant. Significant events in your client's life are always important to document as part of a good clinical history. It's important to have these as baseline questions for all clients and to never assume that a client does or does not have any type of criminal history. 
  4. Your documentation is not meant to hide historical data about your client. One of most common misconceptions in mental health is that confidentiality rules somehow mean we are supposed to hide information that could potentially be harmful to our client. Not so! Confidentiality protects our client's privacy and information to an extent. However, that does not mean we are to hide, downplay, or embellish any client information. Don't muddy the waters in your clinical relationship.

So, yes, you document any reported criminal history. And I recommend you specifically ask about criminal history- ALWAYS. 

This is when it's important to review your paperwork with clients and make sure they know that you keep records, that they can access those records, and when those records may be requested or seen by others. It's also important to reiterate your commitment to their privacy and confidentiality. 

"A client is involved in a criminal act like theft. Is it reportable?"

The short answer here is NO.

Regardless of the severity of the crime, past activity is typically not reportable... unless it falls under a separate reportable category like child abuse or unless someone is telling you about a crime they intend to commit in the future.

These are very important distinctions.

For example, I once had a client tell me they shot someone. However, there was no future identifiable victim, no child abuse, etc. Perhaps fortunately, this happened before I was licensed and I was able to consult with my supervisors and make sure we had considered all the potential reporting scenarios.

If you're unsure or have an uneasy feeling in your gut, consult with a colleague (or two) about the situation. Make sure you're aware of applicable state law and your ethical guidelines. Carefully consider and then document your rationale for reporting or not reporting a crime. 

I hope this helps you if you're ever in doubt about whether or not something is reportable and how to document when your client tells you about past actions.

Remember to stay as objective as possible in all your documentation, particularly related to biopsychosocial history and anything that could later be used in a court matter. 

Unless you are specifically trained in criminal behavior and potential for recidivism, avoid statements about whether or not you think a client will commit another offense. Stick to the facts, things like...

  • Client reports being sober for the last 20 years
  • Client reports attending support groups for the last five years
  • Client reports no prior offense
  • Client reports feeling very remorseful about behavior
  • Client's spouse reports they are now "a different person" and they have not seen any similar behavior over the last five years

Now, tell us! What other tips do you have to add and when have you felt confident about documenting criminal activity? Comment below.

Assessment Dilemmas and FAQ's

assessment dilemmas.jpg

Everyone does intake assessment a little differently. On one end of the spectrum we have clinicians who simply have clients sign a one page consent form and then dive into the client's ongoing struggles and then transition to a traditional therapy session. Not much discussion about policies, not much paperwork, and history on an as needed basis ongoing.

On the other end of the spectrum we have clinicians who use a structured intake document to gather biopsychosocial data and may use up to three sessions to complete this document and formulate a diagnosis. Lots of discussion about history, lots of paperwork and notes, and allowing plenty of time to evaluate symptoms as they develop.

And then a lot of us (myself included) are somewhere in the middle. 

Since you may be curious about my personal take on this, I'll share my own process here. But do please note that I often recommend people do things differently, based on their own practice and experience. It just depends on what works best for you

My assessment process

Personally, I use a structured form and ask clients to complete this form ahead of time. I do this for a few reasons:

  1. I get to read the client's description of their problem, strengths, etc. in their own words. I can then use this to build rapport more easily and it often gives me a better understanding of what's going on, even if we've already had a detailed consultation over the phone.
  2. It saves me time. Just as important as the above, I don't have a huge form to complete during or after the session! 
  3. It helps my memory. Since the form is mostly (if not all) completed I can focus on asking follow up questions, diving deeper into relevant topics or asking about things that may have been skipped. I don't have to worry about doing the whole thing or trying to write down important quotes or information in the moment.

I typically look over the form before meeting with the client and jot down a few notes to myself about further questions or things to explore. However, when the client arrives I first make sure they understood all the paperwork (which they typically sign ahead of time, as well) and review the relevant important things like limits to confidentiality. Then I ask them to tell me more about why they're seeking help at this time and go from there.

So, while I do start out fairly structured, I let things unfold once we have the formalities out of the way. Sometimes the topics we cover are many and sometimes we are much more focused. It really depends on the client. 

However, near the end of the first session, I do make sure to give them an idea about how I think I can help, how I work, and sometimes I will also give a potential timeframe. For EAP or insurance, this timeframe can be very important because it means we're already discussing how to best use our time together since it may be limited. I've found that clients really appreciate this open and honest communication and it helps them become more engaged. 

We will then review what we think our goals for working together are and move on from there. These things often change and that's okay, but after the first session I like for us both to have an idea about how we'll be working together and for the client to be thinking about how they can evaluate me and whether or not I'm the best fit to help them. 

So, that's my structured and unstructured assessment process! I get a formal intake document and a treatment planning discussion in there, but focus primarily on connecting with the client and learning more about their needs and goals.

Your FAQ's about assessment

So what is "recommended" or "best practice?" What works best for insurance? How much time do you need to spend on an assessment? Well, I get a lot of more specific questions like these and below I'm going to address them!

Continuing our FAQ series, below are questions from the QA Prep community about issues related to intake assessment. I do my best to answer these questions based upon my own experience but welcome your feedback below in the comments. Share your tips with us, as well!

"Because assessment is an ongoing process, how in depth are you when completing an assessment at the initial session?"

As I mentioned in my own process above, I am in-depth but only as it relates to the client's current needs. For example, if I am working with someone who is experiencing work stress and not being fulfilled at work, I often do not go into childhood history or past trauma. However, if the client is struggling with managing expectations at home and work because of a difficult relationship with their parents who also provide childcare, that may be a more relevant topic that we dive into.

Of course, we will always gather more information and continue assessing clients ongoing. That is a given.

However, the purpose of an initial assessment is really to make sure you have a clear understanding of the client's need so that you can adequately plan for their treatment. 

That means you want to have answers related to things like:

  • Whether or not you are within your training and expertise to treat this client's need/problem
  • What additional resources or collaboration may be needed (e.g. physician, psychiatrist, couples counselor, sobriety services, etc.)
  • For insurance, whether or not the client meets medical necessity criteria

So, I would say that I am in-depth regarding the "presenting problem" but not necessarily other topics. However, if you bill to insurance companies you may still need to ask other questions and this may limit your ability to be as in-depth, or may simply extend the assessment timeframe. I'll address these specific things below...

"Are there specific questions that must be in the intake assessment? How long should the assessment be?"

Yes, there are a few things I recommend every clinician review as soon as possible with clients:

  • Reason for seeking treatment
  • Goals for working together
  • Strengths and hobbies
  • Current living situation
  • Potential or past feelings/thoughts of suicidality or homicidality
  • Criminal history
  • Substance abuse history

The reason I listed the above things is that I believe these are all things that can become very important information very quickly, depending on the client's answer. For example, if you work in an office alone and sometimes work late at night you will want to know about any history of violent behavior from potential clients. Likewise, it is important to assess suicidality as soon as possible so that you can address this if it is a concern. 

I also think it is important to quickly assess the reason the client is seeking treatment so that you can make sure you are the best counselor to help this client, as well as make sure you provide referrals to additional resources in the community. 

Based upon your specific practice or population, you may also find other things are important to discuss initially. Decide on a structure and then stick with it for a certain length of time to see how it works. There have been quite a few times when I was tempted to leave a question out, thinking it did not relate to a particular individual, but was then surprised that it was quite relevant. So once you decide a question is important for your intake assessment, stay with it. Evaluate every 6-12 months to make sure the questions you ask are still relevant. 

You may also want to consider what has been helpful for you in the past or compare this with your own experience of being in therapy and what you liked about the first session or what you feel was missing.

Pay attention to your intuition and to any gut feelings. I have had a few experiences where I felt compelled to ask a question I don't normally ask and the ensuing conversation turned out to be extremely important. So, while I do encourage a basic structure, I think using your clinical judgement is paramount.

Lastly, for insurance clients (even those for whom you simply provide a super bill), I would add a few other things so that you directly address the important topic of medical necessity:

  • Identify the specific behaviors/symptoms that meet criteria for a diagnosis. Make sure to include how these manifest in real life, rather than simply listing off psychobabble terms like "insomnia," "anhedonia," or "hypervigilance."
  • Identify how these behaviors cause an impairment in the client's life. Make sure you can clearly link the diagnosis to a need you can address.
  • List any other treatment providers. If the client has an ongoing medical condition then you'll want to discuss whether or not collaboration is needed since this is often encouraged by insurance companies.

There are many other things to consider when your client is choosing to let insurance pay for their services, but these are the key things to include when you are assessing clients. 

"A client recently asked that I change her diagnosis from major depressive disorder to generalized anxiety. What should I do?"

Here we are talking about the ongoing aspect of assessment, as well as a legal and ethical dilemma. Firstly, a client's diagnosis should always be based upon their presented/reported symptoms. That is why it is important to include these symptoms/behaviors in your initial assessment, if you provide a diagnosis for clients.

To "under diagnose" or "over diagnose" or change a diagnosis without justification is FRAUD. Fraud is both illegal and unethical.

It's that plain and simple. In this particular circumstance, I would discuss with the client what their concerns are, how they came to this conclusion, and why they are seeking the change. I also find it helpful to educate clients about the concept of diagnoses and will sometimes review the DSM with them. 

Hopefully, this creates open communication as well as a better understanding about mental health symptoms and treatment, in general. 

Lastly, I also want to note here that I am not discounting the client's question. The client may actually be right! Perhaps they have not shared certain things, did some research on Google, and were able to read words that described their experience better than they could describe themselves. In that case, it may be justified to document this change in symptoms or new information and then change the diagnosis. 

The key is to constantly assess and to document your ongoing assessment and reason for any changes

So, let us know what you think about these dilemmas! Add your thoughts or tips in the comments below...