The Great Debate: Long v. Short Notes

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More than once I've heard a therapist say they write very short notes because they don't want to write anything that could potentially incriminate them later on. Many have also mentioned that a lawyer recommended they write as little as possible to avoid writing something that could potentially get them in trouble down the line. I'm no lawyer, but I have to say that I disagree with this advice... and I have some good reasons.

I did a little research project where I reviewed board actions against psychologists, social workers and MFT's in California. The percentage of board actions related to documentation is low, but not as low as you'd think. Consider the following (potential but fictional) scenario:

A female therapist is seeing a male client who reports being attracted to her. She processes this with him in session. This continues for a month before she starts to become concerned that he is stalking her. She consults with colleagues and after the intensity of the situation increases to his showing up at her front door, she files a restraining order and discontinues treatment. Things appear to settle down after a few months and she continues her practice. About a year later she is contacted by an investigator. Her client committed suicide about four months after treatment was discontinued and his family filed a complaint against the therapist. They claim she overreacted and abandoned him. 

When your licensing board begins an investigation what do you think is one of the first things they'll request to see? That's right- your records. What started off as a somewhat common ethical dilemma (that often ends in a much more positive way than this scenario) is now a formal investigation. 

In this scenario, the therapist likely acted ethically. She attempted to process the romantic feelings and only discontinued treatment due to fear for her own safety. However, we will only know her actions were ethical based on a few things, mainly interviews and documentation. Consider yourself in this scenario. At this point, would you likely be wishing you'd written more or less in your notes?

As a quality assurance professional I've read hundreds (possibly thousands) of case notes. There are a few times I've told clinicians they're writing too much or including irrelevant information. There are a few times I've recommended separating certain documents (things like child abuse reports filed) from the client record to keep those documents protected.

However, what's far more common is that I've had to ask the clinician for more information regarding what happened because the clinical note just didn't tell me. It gave me enough information to be concerned or to raise a red flag but didn't tell me how the situation was resolved. That's the key point. It's not necessarily about length, but about the content.

If you can explain your actions or a situation in 1-2 sentences, excellent! And for everyday sessions, that might be sufficient. But when it comes to ethical dilemmas, 1-2 sentences usually doesn't cut it. Don't skimp to save yourself five minutes writing a little more when you could possibly be spending hours explaining yourself months or years later. And is it unlikely you'd need to do that? Yes, thankfully! But it is possible... and it's also easily avoided with good consultation and documentation throughout treatment. 

If you're interested in learning more about consultation and using your documentation as a tool to save yourself time and trouble in the future, sign up for my monthly newsletter (and get access to my free Paperwork Crash Course) or check out my Meaningful Documentation Academy. My goal is always for therapists to feel great about their documentation so they can have the peace of mind needed to do excellent work with their clients.