One of the big things I like to talk about is “de-mystifying the process of documentation.” Every therapist in private practice, and even in most agencies, have a totally different way of writing notes. There’s nothing wrong with that but when we rarely talk about documentation, it becomes a problem.
You see, this means that as therapists we have little framework for what is best practice. Instead, we figure things out as we go along… and sometimes that means we wait a little longer than we should to seek advice.
A while back I met a therapist who asked me what I do. After I explained I help therapists create awesome documentation so they have more time with their clients she laughingly asked if she should be doing more than just writing some notes on her iPhone. I've heard about some pretty crazy things, from being months late on documentation to outright and intentional fraud, but this comment took me aback. She was serious!
I told her she needed a file of some sort and should at least document informed consent as soon as possible. She didn't seem to care a whole lot and this shocked me, then made me a little angry. You see, documentation is not some after thought. It is an important piece of the clinical work we do as therapists.
Aside from the CYA part of documentation (which I do think is very important), your paperwork serves to provide continuity of care as well as a time to reflect on the clinical work you're doing. Much of what we do is ambiguous but if we're not able to put it into words, how are we able to describe the work of therapy to new (or doubting) clients?
If you're in private practice you have the freedom to decide how and when you want to write notes. A great way to connect the paperwork to your clinical work is to use documentation as a reflective time as well. Consider 1-2 things that stuck out to you about that session and how does it relate to previous sessions? Does this bring up something you'd like to follow up with during the next session? Is there any countertransference or reaction you need to process on your own or through a consultation group?
Write it down, process, follow-up with a colleague or research a topic you may need more knowledge of. This clearly makes documentation a clinical process. I believe this way of writing notes will make you a better therapist and keep you growing professionally. It also makes the act of documentation less of a chore.
If you're interested in more tools to make documentation easier and see how it can make you a better clinician, sign up for my monthly newsletter and the free Private Practice Paperwork Crash Course. And feel free to comment below with any tips you have for making paperwork more relatable!