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

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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

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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 are 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!

Documentation Consultations: Case Consult Notes, Collaterals and Collaborations!

This is a "meaty" documentation consult! My good friend and amazing therapist, Rajani Venkatraman Levis, LMFT, requested a consult to create a note template for her own case consultations. So, we create one in this video! 

We also create a template for interaction with collaterals, such as a former therapist, a physician or a psychiatrist. Rajani also discusses a "co-therapy session" she conducted with another therapist and we talk about how documentation might be different for such a scenario.

You can snag these templates by entering your info underneath the video. 

Lastly, Rajani shares a great resource for therapists! It's not related to notes per se, but it's certainly related to all the sitting we do in this profession. Hope you enjoy!

Click here to find out more about Rajani's resource for improving your posture. 

Enter your information below and get immediate access to the two note templates we created in this video!

And let us know what you think about the templates! How do you write your consultation and collateral notes?

Documentation Consultations: Crafting a Notes Strategy

In this installment of our consultation series I'm talking with Erin Findley, a licensed psychologist in California.

We dive deeper into writing notes and talk about some of the things that often keep therapists stuck in the cycle of catching up or avoiding notes. Part content, part process, we review the following:

  • What to do when you need to process sessions before writing notes
  • How to structure your day and schedule writing notes so you maximize your strengths and clinical process
  • How to avoid spending excessive amounts of time on your notes by identifying what is the most important information
  • Using structured therapies like EFT or EMDR to create some structure for your notes without making every note sound exactly the same

And just in case you haven't had a chance to download the sample notes from this series, enter your info below and they'll be delivered straight to your inbox!

Resources Discussed:

Click here to download the EMDR template created by my friend (and amazing therapist!) Rajani Venkatraman Levis.

And you can also click here to check out Simple Practice, Erin's electronic health record (EHR) that offers the option to customize your note templates. 

Now I'd love to hear from you. What other tips and strategies do you have for conceptualizing notes? 

Documentation Consultations: Social Media, Insurance and Notes

Welcome to the Documentation Consultation series! 

In this consultation I talk with Julee Cox, a Mental Health Counselor in Florida. We go through some hefty content in this interview and dive in to some of the following topics:

  • How to talk with clients about insurance and confidentiality from the initial phone consult
  • What kind of privacy clients can realistically expect with insurance
  • What to include in your social media policy and why it may be different for everyone
  • Things to look out for when interacting with clients on social media
  • What are "HIPAA notes" and do you need to prepare for them?
  • The most important thing to include in your notes if they may be seen by insurance companies

I hope you enjoyed this interview! If you'd like copies of the sample notes I referenced, add your info below. 

Resources we discussed in the video:

You can learn all about creating an initial phone consult script by checking out services from Kelly and Miranda of Zynnyme.com.

You can also click here to check out an excellent book by Casey Truffo, where she also addresses these same issues. 

Tell us what you think about the topics we discussed and feel free to add any follow up questions in the comments below.

Documentation Consultations: How To Keep Up With Notes

In this episode of the Documentation Consultation Series, we're talking about some strategies for making notes easier to write so that keeping up with them is more feasible.

In this video I talk with Gina Della Penna, a Licensed Mental Health Counselor in New York. She shares some really common struggles with writing notes and we also talk about things like scheduling. More specifically, we talk about:

  • Creating a schedule for writing notes... and how to know exactly how much time you need to plan for writing notes each week
  • Common fears about who will read your notes and how to protect your client's confidentiality
  • How to use collaborative documentation to solve the problem when you can't think of what to write in a note
  • Tips for how to think about notes so they are easier to write
  • How to conceptualize which note template you're using and how to try out a new one if you're not happy with what you're using now

To download the sample notes I referenced, enter your info below:

Resources we discussed in this video:

If you want to check out Simple Practice, the EHR that Gina uses, click here.

Documentation Consultations: Policies, Forms and HIPAA

We're back with our consultation series where I'm recording consultations I conducted with real and practicing therapists across the country. This time I'm talking with Sandy Demopoulos, a licensed clinical social worker in New York. 

We talk about a lot of things in this interview (which is why it goes a bit longer), but go in depth regarding the following:

  • How the HIPAA Notice of Privacy Practices applies to mental health clinicians
  • How to determine what level of detail to include in your policies/forms
  • What to review with clients who may be court-ordered or working with other agencies
  • Dealing with payment issues, credit card maintenance and collections
  • What to consider with social media policies

I also do something in this interview I haven't done before... I review my own Services Agreement! It's the one that is included in my Therapist's Perfect Paperwork Packet and we go through the various sections that are included. 

Please excuse the phone ringing a couple times in this video... I promise, all the info you'll receive is worth ignoring it for a few seconds!

Resources we discussed in this video:

To check out the Model Notice of Privacy Practices available for free at hhs.gov, click here. Remember to scroll down a bit and select one of the options under the section titled "NPP Provider Files."

To get CE credits for watching the webinar Roy Huggins and I did on the informed consent process, click here

To check out IvyPay, a service that safely collects and maintains credit card information for clients (particularly if you don't use an EHR that provides this service), click here

If you've decided you don't want to deal with creating your own forms at all, then click here to check out my done for you paperwork packet

If you want to check out the more extensive (and free) social media policy available from Dr. Keely Kolmes, click here

If your forms are pretty much set in place but you don't have a court policy, click here to get a great copy from Therapist Court Prep.

Lastly, if you want to check out Counsol, the electronic health record Sandy and I are both using, click here. Note that if you choose to sign up with Counsol as a result of clicking my link, I will receive a discount on my service.

Enter your info below if you'd like to check out my FREE Paperwork Crash Course and you'll also be the first to hear when Meaningful Documentation is officially open for enrollment!

Documentation Consultations: Writing Notes Together

Welcome to the Documentation Consultation Series!

In this series, I record a live consultation with a real therapist who is dealing with a particular documentation issue. We problem-solve, adjust and work out some solutions together.

In this consultation I meet with Melissa Waggy, a Master's level psychologist in Michigan. She wanted to talk about what the heck to put in your notes... so we talk more about this and then we write a note together. 

Click below to watch us review things like...

  • Writing notes when you feel like a session didn't go that well
  • Tips for writing notes more quickly if you're still using paper notes
  • How to talk about other people in your client's life when writing notes
  • What to write when clients discuss multiple topics in one session

If you want to check out the article from Scott Miller that I referenced at the beginning, click here. And you can also add your info below to get the final version of the note Melissa and I wrote together

Still have some questions or have something helpful to add to the conversation? Add it below in the comments!

Guest Interview on The Testing Psychologist

Psychologists and counselors who provide testing definitely deal with plenty of paperwork! Managing all that paperwork can be difficult... and it's another one of those things we rarely talk about that creates a lot of stress. 

That's why I'm so glad that Dr. Jeremy Sharp of The Testing Psychologist is now providing resources for those of us who love testing (yup, I'm one of the testing geeks!). He's built a Facebook community, as well as a podcast in order to share resources.

Jeremy recently interviewed me for his podcast and, of course, we talk about documentation! We get into things like what to include in your informed consent, options for storing records, and what to consider when sharing test results and reports with other parties. 

If you have a testing practice, you'll definitely want to check it out. Click here to listen

The "Best of" Series: Creating a Community Among Therapists, Not Competition

You know that feeling when you connect with someone right away? You're able to joke with one another, share similar values, and the conversation is so natural. That's what it was like the first time I talked with Rajani. 

Rajani Venkatraman Levis is a licensed marriage and family therapist with a practice in San Francisco. She specializes in trauma and EMDR and she is very involved in the larger EMDR community. So involved, in fact, that she (along with another colleague) created a Bay Area EMDR chapter. 

You see, Rajani was looking for a community that she could connect with. And when she had trouble finding that community, she decided to create it herself.

In this interview below, Rajani talks about how she created that community, why it's so important for those of us in the mental health profession to support one another, and why there are plenty of clients to go around.

This video is from an interview I did with Rajani in 2016 for the Road to Success Summit, but I really think it deserves to live on beyond the Summit, so I'm sharing with you here:

Rajani is seriously an example of clinical and business prowess. She has built a very successful practice by owning her strengths, being herself, sharing resources, and providing the services that clients in her community need. She is also on a mission to help other therapists do the same... but without offering courses or business consulting packages. She's doing it by creating community. 

If you want to become part of the online community Rajani is creating, check out her latest venture, www.talkingabouttherapy.com.

She currently has an awesome blog series called "Five Minute Magic" which highlights various things you can do in five minutes to improve different things within your practice. And yes, I did contribute to this series, of course! Click here to read my 5 quick tips for improving your paperwork

Clinical Supervision and Notes: How to train your clinicians

clinical supervision of notes

By far, the most common thing I hear from clinicians is that they didn't receive any (or sufficient) training in documentation.

This is a topic that is very important to all of you. I know because you tell me, you read this blog, you watch the videos and I consistently hear the same thing again and again in workshops. 

Since many people who are supervisors are the same counselors who never received training in documentation themselves, they often don't know where to start with their supervisees.

That's what this blog post is for!

I'm going to outline some different ways to review documentation and notes with your fellows, interns, practicum students and trainees. You may not use all of them, especially if you're new to this, but I guarantee some of these steps will give you ideas for where to start or how to improve. 

1. Review files and notes every week (or however often you meet).

It can be tempting to spend time in supervision focused on the more "interesting" clinical content or to address the crisis of the week. However, your supervision time should incorporate training on ALL aspects of being a clinician. 

And that includes getting paperwork done and evaluating how effective that paperwork is.

Spend some time looking through a client's file, particularly if it's a client about whom you're already discussing a crisis or clinical issue. Not only will this ensure all the legal ducks are in a row, but going back to earlier stages in treatment can often provide clinical insight now that you've spent some time with this client.

2. Read through an entire file, not just that week's notes.

This one is huge! Working as a Quality Improvement Specialist in a few different agencies, I noticed that I would often pick up on things the supervisor hadn't... even when they were regularly reading and approving weekly notes. 

That's because the supervisor was focused only one note.

Looking at that note alone, it seemed fine. However, when read within the context of the client's full file (as I was reading), certain things stand out.

For example, if something significant had happened in the previous session and that session's note had identified some follow up that would happen, I was looking for that in the next note. If that follow up was missing I picked up on it right away because it made the client's story disjointed. 

However, the supervisor could easily overlook this because they were simply focused on the one note and whether or not that content was coherent and professional. Not a bad thing, but taking a different approach every few weeks will provide a different context.

3. Practice together, especially in the beginning.

Do you remember writing your first case note? I do. I remember that I had a few samples in front of me and while they seemed great, they all of a sudden seemed completely irrelevant to the note I was writing. So I simply dove in and tested the waters to see what would be approved.

Now consider if my first experience writing notes had been with a supportive and experienced clinician guiding me. I would've had a chance to ask questions, compare things, get different ideas for wording, etc. 

I know what you're thinking... notes are boring and no one wants to spend time together writing notes. However, I've found this to be the opposite! 

One of the things people consistently mention about my trainings is that they enjoy seeing examples, watching me write notes, and writing notes together. They even really like getting feedback on the notes they've written.

However, this is something that is often nerve-wracking for people and it's unlikely anyone will ever ask you for it. You must initiate but I promise you that 99% of the time, it will go very well.

So take the time to review paperwork, practice writing things together, and continue to do these periodically throughout your supervision time, not only in the beginning or not only for people who appear to be struggling. 

You will create much more confident clinicians who are able to focus on what matters most- how to best help their clients. 

Now you tell us! What have you found to be helpful when working as a supervisor. What did a supervisor offer you that provided you the confidence and tools you needed to be successful? Let us know in the comments below.

My 4 Favorite Assessment Questions

Favorite Assessment Questions Therapy

I've mentioned before that clinical assessment is one of my absolute favorite topics, and one of my favorite things about being a therapist. 

I was fortunate that early in my career I was required to complete LOTS of intake assessments and this forced me to become good at two things in particular- time management and asking good questions (not to mention typing and writing quickly, too!). 

So I thought that I'd share with you my favorite assessment questions that I've continued to find useful over time. Many times, asking these questions leads into powerful and detailed conversations about the concerns clients are bringing to therapy

I encourage you to try them out and adjust as much as you like to make them fit with your clientele in each situation.

1) Describe a typical day for you.

I know, I know. The first one isn't even a question! But it's one of the first things I review with clients when they come in and I find it often leads in to getting more details on the way in which their identified problem impacts their every day life. Going through their typical day prompts them to think of things they may not have considered if I simply had them list off general concerns.

By the way, I do actually have them list off general concerns ahead of time in a quick checklist (available in my Paperwork Packet). But this question often leads in to much deeper topics.

Quick Tip: Adjust this for interviewing parents about child clients.

Parents often have difficulty identifying how often behaviors occur in children. It is important to get a detailed picture of this so you can highlight progress along the way, for the sake of both the parent and the child. 

When parents describe problem behaviors, ask how often they occur by going through their day. How often does the behavior occur between waking up and going to school? How often while at school? How often between returning home and having dinner? How often between dinner and going to bed?

This will help you identify times of day that may be more problematic, triggers to behaviors, and also give you a detailed baseline to visit when you want to praise the progress that is being made in counseling.

2) What strategies have you already used to try and solve the problem?

This question is very important to me because it helps us identify what doesn't work, or how to adjust the strategies already used. Most people have already tried solutions on their own or may have reached out to other professionals for help, whether that's another therapist or a religious leader, an acupuncturist, or a psychic.

Dig in to what led them to seeking out those solutions and why they didn't work. Some may have worked up until a certain point or helped with one aspect but could not address the whole problem.

This will often bring up the deeper meaning behind a more superficial problem or identify other areas that impact the problem for which they are coming to therapy. Then you're able to identify how you can best work together, what the focus is, and where is the best place to start.

Lastly, this also a great way to discover your client's resources, network of support, and personal strengths. These are all things you can use within therapy to assist process and progress. 

3) What would you like to get out of counseling? How will you know you are ready to finish?

Somewhat related to #2, I find this question hugely valuable. This is what helps guide me throughout my work with the client because I need to stay on task.

Of course, things may change and new things will come up over time, but knowing the client's goal helps to steer the ship and know whether something should be passed up (perhaps to address later on), addressed head on, and if you may need to take land at one particular problem for an extended period of time.

This is also a way to help clients who are having difficulty transitioning out of therapy. You can point them to their own goals and reasons they would know they are ready to move on. That's why I do document this one specifically, both by asking the client to write this out before seeing me and in my notes for that session in which we discussed it. 

4) Have you ever been arrested?

A little less "touchy-feely" than the above questions, but this question is still one of my absolute favorites that also provides a wealth of information. 

Note that this is different from asking whether or not someone has a criminal record.

This is a really key distinction. The point of asking about arrests is to gather information about potential problem behaviors that may not have resulted in a criminal charge. This also helps to simplify the question because, in my experience, many people do not view misdemeanors or DUI's as a criminal record and will genuinely answer "No." 

This question will be more or less important based on the type of work you do, but it is still an important question to ask every client in every setting. 

Never assume that someone does or does NOT have a criminal record or arrest history based on their presentation! I have had many unassuming people whom I would never predict having a record answer "yes" to this and it has been important for our work together.

For child and adolescent clients, it is important to follow up by asking "Has anyone in the family ever been arrested?" 

Obviously, this can provide information that you would often not receive by simply asking about a criminal record. And, regardless of guilt or charges being made, arrests of loved ones can significantly impact a child's emotions and view of the world. These are important things about which to be aware. 

There are so many things we could potentially review with clients during our intake assessment. 

This is obviously not an exhaustive or required list. But I have found all of these to be very helpful in a variety of work situations, including private practice. Some of them are in my intake assessment that I have clients complete ahead of time, and all of them I definitely review in person. 

What other questions have you found helpful during the assessment phase in private practice, or other settings? Share in the comments below!

Writing a Mental Status Exam

A few months ago I received a question about writing mental status exams (MSE) and realized I've never talked about this! So, here is some direction regarding all things MSE...

What is a Mental Status Exam (MSE)?

A mental status exam is a brief snapshot of a client's presentation. The MSE is meant to assist with diagnosis, capturing and identifying symptoms, but also to create a succinct picture of the presentation at a specific moment in time.

This means that a person's MSE may appear very different at various stages in treatment, and that's perfectly fine. For example, a client experiencing a manic episode will present very differently at the height of the episode than they will during times of mood stability or during a depressive episode. 

I should note that an MSE is always meant to be completed by the clinician who saw the client, and should include a visual assessment (meaning over the phone would not capture many of the applicable sections). 

The MSE is generally more useful for clients with acute, chronic or more severe symptoms. While it can be useful in all circumstances, many sections may not apply to clients with general adjustment or change of life issues. 

When to Use a Mental Status Exam

The most common use for the MSE is during a clinical assessment. The MSE can actually provide a great source of documentation to support diagnoses for clients. If you have difficulty diagnosing or worry about substantiating diagnoses for insurance companies, try using a mental status exam and then make sure DSM diagnostic criteria match up with the identified presentation. 

An MSE is generally completed during the first 1-2 sessions, and then any other time when re-assessing symptoms. 

That might include regular intervals of time, in order to identify progress, or only as needed during the treatment process. It can be helpful to complete one at the end of treatment to highlight any differences in presentation and celebrate growth.

Some clinicians do complete a brief MSE as part of every progress note but I find this unnecessary in most cases. Of course, that is a preference and if using the MSE every time works for you, great! Just remember to include some information about what transpired during the session, as well. 

How to Complete a Mental Status Exam

Like it or not, mental status exams were created to capture dysfunction, not ordinary function. That's why you'll find most of the categories very "clinical" sounding.

For this reason, it is generally acceptable to simply mark "Within Normal Limits" (or "WNL" for short) if there is no impairment found in the identified section. However, this creates that sense of obligation without purpose in documentation that you know I dislike! 

That's why I recommend that if you are using an MSE, then describe each section regardless of the impairment.

And if you don't find this useful, don't do an MSE! Or, perhaps pare down your MSE so that it only includes the sections you find helpful. These don't have to be long descriptions. Remember, the MSE is meant to be a brief assessment, a snapshot. Keep your answers to just one or two sentences, at most. 

Recommended Mental Status Exam Sections

I am listing these alphabetically, in order to keep things simple. However, these are often listed in notes more by level of depth or order of importance. Many sections are often combined so I have either outlined this or included the common names together.

Affect

Different from and similar to mood (below), affect is a bit more descriptive regarding how a client is presenting their mood. For example, affect and mood may both be depressed or sad. The client describes themselves as sad and appears to be so. 

However, affect can also include things like constriction, range of emotion, and appropriate expression of emotion. For example, mood was depressed and affect blunted. In this example, affect is describing the fact that the client exhibited limited emotion, although they may actually be feeling quite depressed. 

Due to the similarities and how these interact, affect and mood are often combined into one section on an MSE "Affect/Mood." I only included them separately here to review the difference between them. 

Appearance

Self-explanatory, this is literally the physical appearance of the client. Note any unusual physical characteristics, grooming and clothing.

Tip: Stay objective here and avoid phrases like "attractive" that can be offensive and subjective depending on the person describing attractiveness. 

Behavior

This is the physical behavior present during your assessment. Here you will note how the client moved and acted physically. This could be something like frequently fidgeting, shaking leg, unable to sit still, or walked very slowly. It may also include things like yelling or crying. 

Concentration

Here you will note any difficulties with concentration, such as difficulty tracking the conversation, frequently getting distracted or going off task.

Insight/Judgement 

A more subjective measure, in this section you will comment on your perception of the client's insight based on the interview. You may note things like how well your client understands the reasons for their behavior or contribution to a problem, whether or not they recognize the severity of a problem, and what is their perception of how to address problems. 

Intelligence/Cognition

Here you can describe the client's abilities based on the information you've gathered so far. In general, this is really meant to capture the more extreme ends of the spectrum, such as significant cognitive deficits or very advanced vocabulary for developmental age. 

Some clinicians will actually test things like working memory briefly during an MSE by doing serials 7's (counting backwards from 100 by 7's), having a client spell "world" backwards. While impairments here may alert you to something, they are certainly not an indicator of actual intelligence.

Memory

You may do a brief test of your client's memory (asking them to remember something at the beginning and then at the end) but then you again have a very low validity picture of memory. It is best to use this section to comment anecdotally on what was noticed during the session. Did your client leave out important details frequently? Have trouble remembering important events or specific periods of time? Also note if they identify any concern about their memory. 

Mood

This one seems obvious and yes, it sort of is. Mood includes common descriptors of how people are feeling and may use traditionally clinical language or more commonly used laymen's terms. These include phrases like depressed, anxious, worried, sad, euphoric, happy, irritable, etc.

Orientation

This is probably the category most commonly used in the medical field and always included in general mental status exams. Orientation refers to how well the client was oriented to person (themselves), place (the setting in which your assessment occurred, as well as their general location), time (date, time of day) and situation (physical and emotional situation). Note that situation is usually but not always included.

This is typically a very brief section, simply noting something like "Client was oriented x4" or "Client was oriented to person but not time, situation or place."

Perceptual Disturbance

This section has some crossover with thought process and content but could be used to highlight things like hallucinations, if that is a common symptom you see. If so, identify the type of hallucination (e.g. auditory, visual, etc.) and any relevant info.

Speech

Another self-explanatory category, here you will consider anything related to speech quality. This includes things like speech impediments, rate of speech, volume, etc. 

Strengths

This category is not always included in common MSE templates, but I always work from a strengths-based and client-focused perspective, so I'm including it here. You can identify strengths you noticed during your meeting with the client, and also ask the client (or parent/guardian) to identify strengths.

Suicidality/Homicidality

Here you will acknowledge your assessment of these areas and specifically note whether or not the client denied these, has a plan, has ideation only, etc. 

Even if your client was noted to be suicidal with a plan, don't feel the need to include extra information here. That will all be in your progress note where you describe your assessment in more detail, along with the identified plan. 

Thought Content

This section captures what was the main content your client presented during your session, as well as any noteworthy content items that came up. This may include delusions and hallucinations, if you prefer not to have a separate category for these symptoms. 

Regardless of things like delusions, this is also the area to include things the client focused on as important. That may be feelings of guilt, preoccupation with a particular topic (video games, sex, a specific person, etc.), irrational worries or even phrases that were repeated throughout. 

Thought Process

While content focuses on what was discussed/presented, process focuses on how the client presented that information. This includes things like ability to think abstractly, connections made as explanation for behaviors or mood, associations and ability to stay on track, flight of ideas, or magical thinking. 

Yes, there may be some crossover here with things like concentration and insight/judgement but this section really pulls those pieces together to describe how the client views the world and themselves.

Create Your Own Mental Status Exam

If you're in private practice then you have the flexibility to use which sections you like, complete an MSE whenever you feel it is relevant, or even avoid it altogether

I recommend you look through the sections and then identify anything you think would be helpful to document during intake assessments, then anything that may be helpful to track over time at various intervals, and anything you'd like to capture at the end of treatment for a more objective view of progress. 

You may find certain sections more or less relevant for different clients, and that's okay. Think about your current clients. If a section applies to at least half of them, then it will likely prove useful to you. If not, then scratch it and just add that in when it's needed.

You can also create an "Other" category for random things that come up but don't fit anywhere else. Simply use that as your catch all and then take note if you find yourself including the same thing over multiple clients. Then maybe it should become it's own category.

You have the power here to make the mental status exam whatever you'd like it to be for your practice. So make it meaningful to you and helpful to your clients. Otherwise, there's no point!

Let us know in the comments below... do you use a mental status exam in your practice?

What tips have you found to make it meaningful and easy to complete? 

5 Counterintuitive Ways to Improve Your Notes

By far, the most common concern presented to me by therapists is note quality. Clinicians are hoping their notes are good, but since no one else reads them or since they receive little training in this area, they actually have no idea if the quality is there.

For content related to writing, I've got sample notes available for free inside my Private Practice Paperwork Crash Course. You can also check out this blog post that has an example of necessary content and how to pare down note length.

Today I'm sharing with you five counterintuitive strategies that will help you improve your notes, no matter what your current quality may be... and they're all things you can try out right away!

1) Take a break

One of the best things you can do for your productivity is to take regular breaks. Whether it's five minutes every half hour, 10 minutes every hour it doesn't matter. The key is that you must schedule them in and take them!

Even if you feel like you're in a place of "flow" and working for over an hour, it is rarely helpful to continue working without a break. Trust me, as someone with ADHD, I know this struggle!

Lucky for you, I've made it a little easier to take a quick five minute break. Why not listen to some music that will help you rock out, give you a dance break, or pump you up for more work? Check out my new playlist on YouTube for some epic songs to keep you going... after a break to rock out or dance: 

Rock Out Dance Out Break From Notes Playlist

2) Reflect first

Taking the time to reflect on your session, your client's progress to date, any struggles you're encountering, etc. will clear your head and help you focus when writing your notes. It doesn't have to be long but pause for 1-2 minutes before your note and make sure you are in the right head space.

3) Plan ahead

You've heard that quote: "Fail to plan and plan to fail." That definitely applies to your notes! Make sure you give yourself enough time to write notes each day, allowing time for other administrative tasks at a different time of day.

Many counselors run into trouble because they forget to plan out note writing time when figuring out their schedule. Even then, they'll often add that time for general administrative tasks including notes. Doing this usually means notes become a last priority, behind answering voicemails and emails. 

4) Read through old notes

I recommend you spend time each quarter looking through your client's file. This will actually make you a better writer because you'll catch things you may have missed or recognize common phrases you like to use in notes.

This review time will also help you see how well you're able to blend sessions together to tell the complete journey your client is taking with you. Don't worry about spending hours on this. Simply plan for one hour each quarter and see your notes grow in quality!

5) Let your client help

Lastly, let your client help you write notes! Collaborative documentation has not only shown to be a faster way to write notes, but clinicians commonly report it also helps improve their note quality. They feel better about the content because it is up to date and their client has helped summarize things from session.

Plus, if your client is contributing to their notes each week, the fear of your client seeing their records is pretty much eliminated. ;)

If you'd like a more in-depth training related to collaborative documentation, consider signing up for my Webinar CE Club. There are already four previous trainings waiting to be viewed, one of them on how to incorporate collaborative documentation. You'll also get access to a new webinar (and CE credits!) each month.

Which of these strategies is the most helpful for you? Which one do you plan to try out this week? Let me know in the comments below!

How to Avoid Writing Notes

Sometimes we just need a little fun! Check out this video for some great ways to avoid writing your therapy notes:

What's your favorite way to avoid writing notes? Share your biggest vice in the comments below. Better yet, share your tips for overcoming these things!

And if you want help catching up on those notes, check out the Paperwork Catch Up Group starting Monday, January 9th.

Happy writing! 

Drafting Your Personalized Note Template

One way I recommend counselors save time on notes is to choose a notes template and stick with it. In my Private Practice Paperwork Crash Course I review five different types of templates you can use and these are basic copy and paste topics you can use across the board.

However, I do get feedback occasionally that some therapists have adjusted the templates and when they do this, therapists tell me the template is much easier to use and much more meaningful to their work... because it's personalized.

So, I thought I'd review all the different components of common therapy notes templates in case you'd prefer to simply pick and choose what works for you. These components all come from the following note template formats: DAP, GIRP, PAIP and SOAP.

I encourage you to check out what sections appeal to you and seem meaningful to your practice. Choose those and create your own therapy notes template that you'll find easy to use every day.

These are simply listed in alphabetical order, with no identified level of importance.

Assessment

This section focuses on the clinical assessment of the client's symptoms, progress, presentation, etc. Here you can add more clinical language and also outline how the session may interact with previous sessions or experiences, as well as highlight things you think may be important to monitor.

Data

This is the same as the "Objective" section below (so just choose one). Here you will add information that is objective and behavioral. These are things that occurred in session and any lay person would be able to describe. This could include quotes, acting out, crying, refusing to participate, nervous movements, etc. If it could be heard or seen on a video camera by a person on the street, then it goes here.

Goal

This is typically at the top of the note and includes whatever goal(s) the client is working on. Rather than making things complicated, simply copy and paste from your treatment plan wording. Keep it simple and direct, but also monitor to make sure your sessions are really in alignment with the goals you are including with each note.

Intervention

These are the actions of you, the counselor leading the session. Whether this is something you did passively (like building rapport) or more actively (like teaching a technique), this section is meant to capture where you directed things and how you responded. If you tend to review or teach techniques, direct clients in certain behaviors or challenge and examine thought patterns, this will be an important section for you to include in your notes.

Objective

This is the same as the "Data" section above (so just choose one). Here you will add information that is objective and behavioral. These are things that occurred in session and any lay person would be able to describe. This could include quotes, acting out, crying, refusing to participate, nervous movements, etc. If it could be heard or seen on a video camera by a person on the street, then it goes in this section. 

Plan

The plan is one of the most important components of any notes template and I recommend you have a Plan section regardless of what other sections you include. This is where you identify follow-up, whether that is for you or the client. Here you can clearly identify how the client may incorporate what was learned in session over the next week. And you will also include when is the next planned session. This is crucial for documenting your continuity of care.

Problem

Similar to the "Goal" section, the Problem is whatever problem area the client identified they would like to work on in therapy. This may be just as specific as a goal, or may be somewhat vague, such as depressed mood or anxiety. Regardless of the specificity, this will help guide your treatment and allow you and the client to know you are on the same page with where things are headed.

Response

This section is the opposite of the "Intervention" section because it is focused solely on the client and how they reacted to things during session. Similar to the "Data" section you will want to include objective information that would be easily seen or heard by anyone in the room. However, if you choose not to have an "Assessment" section, you may also include more subjective responses made by your client as well. Also, remember that refusing to participate or react to something is also a type of response and should be included here. 

Subjective

This section is opposite to the "Objective" and includes information shared or observed during the session that is either subjective to you or to the client. This could include things like a prognosis or an interpretation of a response. It could also include subjective statements made by the client themselves.

So, how does this all look if we put it together in new formats? You'll notice that some sections are similar and I never recommend duplicating your work, so choose what you like best to have a complete note.

Some examples could be: 

PDAP (Problem, Data, Assessment, Plan)

GOAP (Goal, Objective, Assessment, Plan)

PIRP (Problem, Intervention, Response, Plan)

PIRAP (Problem, Intervention, Response, Assessment, Plan)

SOIAP (Subjective, Objective, Intervention, Assessment, Plan)

The amazing thing about being a therapist in private practice is that you get to make these decisions! Don't let it overwhelm you, let it make you a better clinician by personalizing things to yourself and your clients as much as possible. 

One last recommendation is to consider using one format for ongoing notes but a different template for assessment. A participant in my Meaningful Documentation program did this and found it was much easier for her to write the more in-depth assessment note for the first session but then she could take things down a notch going forward. 

Play around with things and see what works for you. Don't make it too complicated but also understand that sometimes creating these systems does take time. However, once you have a clear format for writing progress notes you are able to do them much more quickly and with less mental effort. 

That way you can spend time on what is most important- the clinical work!

Leave a comment below and let me know what you decided if you choose to mix and match. I'd love to hear and so would many of your colleagues!

Catching Up On Notes: An Interview with an Honest Therapist

We've ALL gotten behind on notes. Yes, all of us. 

The problem is that we never talk about it. And the more behind you get, the LESS you want to talk about it. But that makes the problem worse, and so things go on and on until you feel overwhelmed.

That's exactly what I'm talking to Dr. Traci Lowenthal about today. Traci got behind in her notes, and was courageous enough to let me interview her about how she's getting caught up and how she plans to avoid this happening again in the future.

Click below to check out the video and share this with your friends! I guarantee you know at least one counselor who is behind in notes right now, but too ashamed to discuss it. 

Wasn't she awesome to share her experience with us?! 

If you're also behind in your notes but not sure how to start getting caught up, or if you need some extra motivation, check out the Paperwork Catch Up Group

This is a group where you get the practical tips as well as the moral support you need to get caught up and stay caught up on notes. 

And if you have your own tips and tricks you'd like to share, leave a comment below! Remember, you're not alone.

Writing Your Client's Journey: Interview with Jo Muirhead

While blog posts are helpful, sometimes you just want to hear what someone else is doing and model things after them! That's what I'm doing with the regular "Writing Your Client's Journey" series and to kick things off I interviewed a very successful group practice owner in Australia, Jo Muirhead

Jo shares some excellent tips on things like streamlining, creating systems and encouraging your motivation to get paperwork done.

You'll notice some sound distortion in just a few spots but it's very brief and there's a ton of great tips so stick with it! And if you've only got a few minutes to check things out, scroll down further for the interview highlights.

My favorite quote from this interview is early on when Jo says about paperwork and systems, "If you can't learn to love it, you've got to respect it because hating it helps nobody."

In the beginning of her practice, she tried to customize her systems and forms to meet each individual client's need but then found out that wasn't working as her practice grew. So, Jo started to create systems for getting all the mundane but necessary stuff DONE.

Creating a system for yourself makes things more simple and easy. Without these in place, you can easily be distracted from the work you really want to do- your clinical work with clients. 

Prepare for growth by having directions for things written down for anyone who may need it later on (e.g. an assistant or a new clinician). This can save you hours of time... Jo and her team set up one system that turned end of month financials from a 10 day task into a two day task!

Specifically, some tips that Jo shared during the interview are: 

  • Set up a checklist for each task
  • Create a centralized place and system for all tasks
  • Teach a child or a partner (or team up with another clinician) how to implement each task to identify holes in the system
  • Schedule everything (especially notes and accounting)
  • Use LastPass to manage all your passwords for every site that requires a password

Important things to focus on streamlining: Intake and discharge

Important things to keep up with regularly: Notes and bookkeeping

Jo also had a great tip for those times when you become overwhelmed by a task. Ask yourself, "What could I have done to make this easy on myself?" Then focus on changing that one habit to improve things in the long-term.

And the big payoff from putting in all this work? Once you have a clear idea of how long it takes you to complete a task, you can decide if it will be worth delegating and, if so, you know what to expect from that person!

Feel free to share in the comments below. What have you found helpful for simplifying paperwork and other administrative tasks? 

Want to learn more about Jo and the coaching services she provides for others? Click here to learn more!