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.

We keep your information secure via our Privacy Policy.

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.

We keep your information secure via our Privacy Policy.

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...

Therapy Notes: Your FAQ's Answered

therapy notes faq.jpg

Dealing with notes from months ago.

Worrying about notes sharing too much information if revealed in a legal proceeding.

Spending too much time writing notes because of worries about insurance audits.

These are the concerns many counselors share about their case notes. 

I've been collecting a database of questions I commonly receive and figured it's about time I focused on answering some of these! So, this will be the first blog in a series focused on FAQ's. 

Remember that my goal is never to tell you exactly how to do something. I am a strong believer in multiple correct answers or ways of doing things (in most circumstances). But I do hope to offer you some food for thought in my answers below.

These are all real questions or concerns brought up by other therapists... and I hear them over and over again:

 

Writing Notes Late

"How late can I write notes if I'm behind?"

You can (and I would say, should) write any note that isn't written. That means if the note is from last year, write it! If it's from last month, write it! There is no expiration date on writing notes.

Now, if you're like me, there may be an "expiration date" for your memory. And there are certainly expiration dates for things like insurance claims, so that's another story. But having a complete story in your client's record is always important. 

I do recommend that if it's been a long time (this is subjective but let's say more than a month), include something like "Late Entry" at the top of your note. 

You're not trying to hide anything and since you should sign and date all notes on the date of entry, that won't match your session date. This is simply providing an explanation for why those dates are off.

 

"What can I do if too much time has passed since the session and I don't remember anything to write as a note?"

Sometimes this happens. And it sucks. 

Do what you can but NEVER make up information that you don't remember. 

If you honestly can't remember what happened but you're certain your client did show up for the session, write a very brief note like...

Late Entry. Client attended session. Addressed treatment goals. Next session planned for xx/yy/zz.

Is that a good note? Of course not. But let me tell you, it's still better than no note at all and you're not compromising your integrity. Admit that the situation sucks, create a plan so it doesn't happen again, and move on. 

 

How Much To Include In Notes

"I feel I write too much... that is how I remember things actually. Should I then do a summary for the legal notes?"

I feel the same way! As I've mentioned before, part of the reason I stay on top of notes is that I know I have a horrible memory and won't be able to write them a week later if I got behind. 

I recommend asking yourself some key questions while writing:

What was the theme of our session?

What stood out to me as important about our session? 

What seemed important to my client during our session?

What do I want to follow up on? 

What do I think will be really important to have written down for later?

Try to keep your answer to each of those questions to one sentence, then use that as the basis for what you include in your notes. This process may take a little more time initially, but you'll be able to train yourself to think about these things when you sit down to write notes.

The process will get easier and faster over time. And you know what? You may simply write a little more in your notes than another therapist. And that's okay.

And if writing a lot or taking a lot of time on notes is a concern for you, I actually don't recommend you write a summary for the "legal" notes. (This would mean writing freely as process notes and then writing a summary for the progress notes- see the section  on HIPAA below for the difference.)

Why is that? Because then you'll create more stress for yourself and spend even more time on notes! Not what we're going for here. Simplify things instead.

It's okay to have objective information in your notes. We worry a little too much about having "too much information" in our progress notes. But if you want some more guidance on how to pare things down, check out this blog post where I give an example of how to do that.

 

"How much specific detail do you include regarding session details and/or thought process in how you arrived at a decision?"

Here's a vague answer you'll hate- however much it takes to explain your rationale.

Seriously though, if you're in a situation where you're documenting why you made a clinical decision, you're likely dealing with something that could potentially be high risk or an ethical dilemma or the like. This is NOT the time to skimp on information!

Provide the applicable laws or ethical principles, information from research or consultations you did, and how all of those things contributed to your decision. This is the basis for your rationale. 

Sometimes this can be accomplished in 1-2 sentences, sometimes it will take 1-2 paragraphs. It simply depends on the situation. 

 

Insurance Worries

"I'm finding myself writing 1-2 page progress notes. Since I've started taking insurance, I've become stressed with note taking."

Notes for clients using most insurance companies aren't drastically different from notes for clients who pay privately. The biggest difference with insurance is that you want to consider medical necessity. 

I have a much more detailed blog post on this topic here, but I can summarize by saying that you do want to make sure you're following a treatment plan that is focused on the client's diagnosis and you want to address two things in every note:

  1. Progress made
  2. Ongoing need

This is the fine line with insurance. If therapy isn't helping your client in the long-term, they may choose to no longer pay or not to approve further sessions. However, if you only focus on progress then it appears your client no longer needs services.

Insurance is often not concerned about your specific interventions or treatment modality (although it does apply in some cases). They simply want to see that they are paying for a service that is meeting the member's needs. 

And yes, they usually do want to see how they can do that more cheaply. Let's be real. 

So make sure you consider that, too. How is ongoing therapy keeping your client from deteriorating, from needing more intensive treatment? How is it improving their health or relationships? These are all things that make therapy a very cost-effective treatment when compared to things like hospitalization or tests for somatic presentations of symptoms. 

 

"How to document in a problem focused way to satisfy insurance, disability, etc when the session is strength based and optimistic."

Continuing our discussion from the answer above, you want to include honest information about the progress (or lack therof) that your client is making, as well as their ongoing need. 

I definitely work from a strengths-based perspective, but that doesn't mean I'm ignorant to the reason my client is seeking therapy.

They have a concern and that manifests itself in ways that are impacting them negatively. To gloss over this or pretend it's not a concern is actually quite demeaning, disempowering and invalidating.

Documenting this and addressing it is a critical component of enacting change and working through any problem. Documenting this does not place blame on the client or invalidate any of their strengths. In fact, it does quite the opposite.

So yes, include the strengths and the wins. Absolutely. 

And then also include what continues to be a concern, a problem, a need. Identify what didn't work or continues to be a struggle. Document the full journey your client is on and you'll have a beautiful narrative that highlights their resiliency and strength throughout. 

 

HIPAA & Psychotherapy Notes

"What are psychotherapy notes based on HIPAA?"

This is a BIG topic and for a more complete answer, I'll direct you here to an article from Simple Practice's blog. But here are the basics with psychotherapy notes per HIPAA...

  1. Psychotherapy notes are what we commonly refer to as process notes.
  2. Psychotherapy notes are optional and MUST be kept separate from the client record to receive their distinction.
  3. Psychotherapy notes are NOT progress notes (case notes) that discuss ongoing treatment.

Why they decided to use such a confusing term, I'll never know! But per HIPAA, psychotherapy notes are those optional notes you might write to yourself about sessions, clients, to jog your memory, etc. As such, they receive special privacy and clients are typically not entitled to them. 

However, these never take the place of progress notes, which are the ethically and legally required notes we do need to take. 

So yes, if you choose to write process/psychotherapy notes, you are choosing to write two different notes for sessions. For some therapists, this is a really important part of their own process. For others, it is simply an extra burden and they choose not to do it. 

In case you're wondering, no, I don't write process notes. But I also share notes with my clients on a regular basis, so I often do things a little differently ;) 

 

"It appears that process notes can also be subpoenaed. How do we keep non clinical notes for our memory sake?"

Yes, they can! It is a common misconception that process notes (psychotherapy notes as discussed in the previous question) receive such special treatment they cannot be subpoenaed. 

However, it is very rare that psychotherapy notes are ever subpoenaed and I would guess that if they are, whomever is requesting them is often intending to request progress notes instead. It is always best to call your client and discuss the reason for the subpoena, see if they are providing consent to release records, and to then assert privilege when applicable. 

Unfortunately, since the definition of psychotherapy notes is basically any notes you take about clinical treatment for your own purposes, I can't think of a way to ethically do that so they are never potentially subpoenaed. 

Remember though, that process notes can be whatever you want them to be. That means you can use abbreviations, shorthand, your own illegible handwriting... whatever you want! You do not have to worry about these notes being ready for scrutiny. 

That being said, the one thing I would encourage you to consider is how your client may react if they saw the notes. Although it is highly unlikely that will ever happen, you wouldn't want to have anything that could be offensive. I'm not saying to avoid writing things that are true, but do consider how you word things. 

 

What do you think about these situations? You may have another great suggestion or factor to consider. Let us know in the comments!

Review of Notes and Electronic Health Records for Therapists

It's about time I did a review of some Electronic Health Records (EHRs). I get questions ALL THE TIME from therapists who want to know...

  • What EHR do you recommend?
  • What is your favorite EHR for notes?
  • How do you set up paperwork inside your EHR?

Today, I am answering those questions by providing an overview of eight different EHRs. There are many more EHRs available and I simply haven't been able to check them all out. However, all of these below are ones that I have either tested and played around with or received a virtual tour from staff at the EHR (super thankful for all their time answering my questions and showing me around!). 

Important note before you dig in:

I am not personally endorsing any of these EHRs for your practice. I strongly believe that with all things documentation, you need to use what works best for you and that will often be different from what works best for other people (including me). So, please do use this as a resource to get an idea of what you might like and then try it out for yourself.

Although I do receive an affiliate commission for some of them, I am 100% honest about what I like and don't like about each EHR and let the EHRs know that up front, as well. I know you certainly don't want me holding back ;) 

To be as fair as possible, my reviews of EHRs for therapists are listed in alphabetical order:

Counsol

Okay, let's get this out of the way- yes, this is the EHR I am currently using. Why did I choose it? Because it offers integrated video sessions for online counseling and because it offers a client journaling feature, along with all the other typical EHR goodies (billing, scheduling, notes, text or email reminders, client portal, etc.). I will be honest though, and say that I haven't used these features nearly as much as I originally anticipated.

Now, let's get into the specifics here:

Counsol does not have a clean, modern look like some other EHRs, but the function is the same. For notes, there is one template with mutliple sections. You can choose which sections of the note you want to include or hide, although the note itself is not super customizable (which is a big disappointment for me, personally... you know, since I'm all about making documentation meaningful and personalized!).

The notes provide checkboxes for interventions and the assessment section, as well as free text fields to add other notes, and provides a WHODAS score and diagnosis dropdown list so you can make sure you're staying on track with symptoms. As I've mentioned before, beware relying on the check boxes, which would be very easy to do here and give you almost no info about what actually happened in the session.

Counsol also allows for the option to have separate internal notes (process notes) or specific free text notes that are shared with the client. I really enjoy this feature since it makes collaborative documentation and ongoing communication with my clients really easy. If I mention a resource in session, such as a book or website, I simply include the link or name in the note and they can look it up any time. 

If you don't want to share notes with your clients, this is an optional feature, so don't let that part freak you out.

One big caveat for those of you who tend to be disorganized or fall behind in notes: Counsol does not remind you if a note is not complete. There is no way to tell if a note has been started or finished without actually going in to the client record. So, if you're the type who needs those reminders, you may want to check something else out.

Another option for personalized notes or treatment plans is to add these as a form within the system and write that way, although it's a bit more cumbersome. I do love the form creation within the system so clients can easily sign or complete paperwork ahead of time. And you are also assigned a customer service representative who will help with any set up or questions. No need for emailing a generic info@ email.

ICAN Notes

This may possibly be the most robust EHR available for mental health professionals. It has many cool features that could be conceived as really cool, but possibly overwhelming... depends on your definition of both those words ;)

Within all sections of the EHR there are “shrubs” to prompt you for writing things more easily. These are shortcuts that you can create on your own for phrases or templates you regularly use for assessments, notes, etc. There are also pre-created shrubs if you want to go with what's already there. These seem really useful for prompting counselors on things like what to ask for justification of a specific diagnoses, adding in severity, complexity, writing an MSE, etc.

There are also specific phrases and templates for group and play therapy, which many EHRs overlook. And if you treat substance abuse, there are tons of pre-created phrases and templates related to this, as well. 

There is also a client portal with option to email inside the EHR, show notes to clients, have clients sign paperwork in the system ahead of time, and you can send forms directly from within the system. You can also use a custom form builder and there is the ability for clients to add historical information for assessments prior to coming in.

Yes, this is a robust and potentially overwhelming EHR. However, they do offer unlimited training sessions that are one-on-one, and this is included with pricing. Another feature you won't get from many EHRs. 

Mentegram

Mentegram is a fairly new EHR and is very receptive to customer feedback. I've been impressed by the speed with which they're able to make adjustments to their system and add requested features. This could be a huge benefit to joining in the earlier stages.

This EHR offers the ability to do video sessions within the EHR, which is always a nice feature for clients to have a "one stop shop." There are multiple notes templates (DAP, GIRP, PAIP, SOAP... hm, sound familiar??) as well as a free text note available for anything else you want to write.  

You are able to upload and use any forms, and do scheduling and billing. One really cool and unique feature of Mentegram is the ability to integrate client data from outcome measures or progress based on what clients enter in the client app. Yes, that means you can assign your clients a quick questionnaire to do and the information is uploaded without anyone needing to do anything further!

So, you could assign a client to track their sleep every day or use it to have clients check in about their mood once a week, etc. Other EHRs usually charge extra for anything like this and I really appreciate what Mentegram is doing here. 

PsychScribe

This is an all in one app that you can easily use on your phone or tablet. Yes, this EHR is only offered as an app so it is not currently available on your desktop computer.

PsychScribe has a great layout and simple design, making it easy to follow and use. There are lots of note templates, although none are customizable and there is no option for only a free text note. So, I could see that being needed every once in a while.

If you like a lot of prompts and don't want to think too much about what to include in notes, this might be the EHR for you. The notes can appear a bit long but really would not take long to complete since it is a lot of checkboxes and prompting. It also has specific options for play and sand tray therapy, with the ability to directly upload a picture to the note.

PsychScribe is NOT for you if you bill insurance electronically, unless you want a completely separate system. It is also does not offer the option to charge credit cards, so I recommend using Ivy Pay instead (also an app that's really easy to use).

There is no client portal or ability to upload forms, so you would need to do forms on paper, then take a picture to scan into the client's file on the app and then shred the paper (yes, you can shred paper after you upload it electronically).

Simple Practice

This is a very popular and affordable EHR option that also continues to improve and add features based upon customer feedback. SimplePractice has a beautiful layout that is similar to the clean look of Apple products. It offers a client portal, the ability to upload forms, have clients complete forms ahead of time, online scheduling and messaging, etc.

For notes specifically, you can use their DAP template or create own template. However, you do need to sign up using the mid priced tier if you want the ability to create your own notes template (and you know I always want this ability!). There is also a separate section available for those of you who write process notes, so you can feel they are separated from the main record.

For those of you who need it, SimplePractice does prompt you to write your notes and will keep count of how many notes are pending. However, remember to LOCK your notes after you've completed them. Locking your notes is the same as signing them in the electronic world. Unlocked notes are essentially unsigned notes. 

Most therapists who use SimplePractice love it and recommend it to others. They offer weekly trainings and office hours to ask questions and are very receptive to adding new features that are commonly requested. Plus, they had me speak at their live event last year and then write a guest blog post so I think they're awesome for that ;) 

You can click here to check out my guest blog post on How to Use an EHR Like a Pro.

TheraNest

Very similar to the EHR above, TheraNest offers a simple, clean layout that is easy on the eyes and easy to navigate. There is a client portal, forms uploading, scheduling, and billing. They also offer easy pricing if you want to add other clinicians, charging by number of clients rather than number of clinicians.

Their notes are also simple and allow for customization. They do offer a treatment planner but this wasn't my favorite feature since it seemed overly complicated.  But my personal pet peeve is the whole Goal-Objective-Intervention thing, so that may just be me. FYI- I think you can make goal and objective the same thing, but I'll save that for another treatment planning blog post ;) 

TherapyNotes

Another robust EHR that offers a lot of templates and pre-formatted options is TherapyNotes. One cool features is that notes have the PQRS built in for those who bill Medicare. 

However, you are not able to customize notes or hide features within the pre-created templates and there is a LOT of information in those notes! Some information is required so you have to write something whether you value that field or not. Other sections in the pre-created templates are not required so you could skip them.

However, I never like using this as an option since things get messy when trying to remember what section you completed last time.To avoid this, you are able to rename templates and there are a few different options so you could create your own from a couple of the free text field options. One benefit of using this type of system is learning what you commonly write over and over and then copying and pasting some of those common phrases to save yourself time.

Justin from The Testing Psychologist likes this EHR for easy use with notes for psychological testing. The note adds up time for each test completed, has drop downs for different tests and prompts for other things like to whom the report was released and if feedback was given. Definitely a unique feature and very cool for testing peeps! 

This EHR also pulls in information from the treatment plan and you can use the history feature for previous similar entries to save yourself time typing the same thing over and again (although, beware writing the same notes too often!).

If you do intake assessments in person, this uses a note to complete the intake. The intake note asks for diagnosis justification after assigning the diagnosis. It would be great for people who want reminders in their to do list and reminders for what to write in each section but beware using too many drop downs and losing a more personalized description of what's really going on in your sessions.

Therapy Partner

As far as group practices go, this may be the best option I've seen. Therapy Partner was founded by a therapist with a group practice so a lot of the intuitive and nuanced things about having multiple locations and/or multiple clinicians are integrated with this EHR. For example, you can give permissions to different users so that clinicians can view and document for their own clients, but not see clientele at another location. 

Regarding documentation, Therapy Partner meets my standards for customization! They do have a few standard templates to choose from, with various sections and check boxes for things like interventions. These templates also integrate with the current diagnosis listed for a client (if applicable).

However, if you want to use your own template, you can send them a Word document version of your personalized template and they'll create it in the system for you! I love this service. 

There is no specific or integrated treatment plan within Therapy Partner, but you would easily be able to give them a Treatment Plan template using the above system and then complete that document for your clients as needed. 

They will be releasing a client portal in late fall/early winter 2017. This is probably the biggest feature currently lacking for Therapy Partner but they seem to have a good sense of customer needs so they have been testing this feature with a few current clinicians and it will be releasing soon.

Getting started with Therapy Partner is pretty easy since they offer a free trial. You can also use the promo code "QA Prep" and get two months free, rather than just the typical 30 days to try it out. They also provide extensive help with set up, walking you through things like integrating your merchant account, adding clients and uploading forms. You also have an assigned customer service representative so you have a specific person to call when you have support needs later on.

WeCounsel

WeCounsel is another EHR that offers the ability to do video sessions with clients inside the EHR and gives you that one stop shop for all things client file, billing, online sessions, etc. 

With WeCounsel you can easily add a free text note or use of their many templates. They have a detailed intake template if you prefer to ask questions of clients in person rather than having them do paperwork ahead of time. I also like the ease of adding an addendum to any note- it shows up nicely underneath the note and is super quick for those circumstances when you realize you've locked a note but forgot to add something important.

It is very easy to read through all the notes on a screen by scrolling down so reviewing the file is simple and won't take you a ton of time. WeCounsel does not allow for creating a new template, so you'd have to choose the free text field and add your own template each time for personalized notes. Personally, the pre-created templates have too much info for me, but if you want something really directive, you are able to use them. Again, to each his/her own!

The overall client file interface does not feel very organized and forms are uploaded to show in a long list, which can become confusing if you do scan and upload a lot of forms rather than doing them within the system. 

That's that!

So, what do you think? Do you use one of these EHRs and have additional things you want to share? Don't see your EHR reviewed and want me to reach out to them for a review?  Let us know in the comments below!