The best way to have a positive attitude about clinical documentation is to look at the real purpose behind it. Therapists often hyper focus on certain areas of purpose, such as liability or insurance reimbursement. However, the real reason we do paperwork is to provide the client’s story.
Every chart tells a story of the client’s work with you. As an objective reader it tells me what you focused on in treatment, how often you met with the client, and whether or not you followed up with certain things.
You spend hours upon hours with your clients doing meaningful work… and it all gets summarized in that little chart in your office (or on your computer).
What happens when you look at the information in that chart? Do you get a sense of the growth that took place? Is it clear how you handled the struggles presented to you? Is it clear that you talked with your client about informed consent and your guidelines regarding confidentiality?
I challenge you to take out 1-2 client charts (bonus points if they’re long-term clients) and look through them cover to cover. Think about things from an outside perspective. Is there anything you read that you find yourself explaining more in your head? Is there anything missing or is it a little too detailed with things you realize don’t relate to treatment (no one needs to know whether or not your client brought their Starbuck’s drink to session)?
Mostly though, how does reading that chart make you feel? Does it bring out those same feelings that arise if you were to talk about your client? Does it make you feel proud of the progress and things discussed?
My hope is this exercise will help you see what you’re doing well and identify if there’s anything you may need to work on or consult with others about. If that’s the case, feel free to check out my upcoming program, Clinical Documentation: Everything You Never Learned in Grad School.
And if that’s not for you (or even if it is), meet with a colleague so you can share ideas and help one another out. Remember, we are one another’s greatest resource! Happy writing!