Making Documentation Meaningful

forms and policies progress notes Apr 12, 2015

There are a lot of emotions around documentation for therapists, most of them negative. Fear. Resentment. Overwhelm. Anxiety. Anger. I hear all of these and many more mentioned in networking meetings and Facebook groups. And it's commonplace; like we're just supposed to accept this is how it is and trudge through it for our entire career.

But what if paperwork didn't have to be that way? 

It's now been a year since I started blogging about documentation and I've been getting awesome feedback from therapists around the world. My favorite thing to hear is that I've made someone's work easier by helping them to connect with paperwork. That's right, it really is possible to have positive emotions around paperwork! 

Confidence. Satisfaction. Connection. Peace. Joy. 

So, how is it that some therapists have gone from overwhelm to peace? From anxiety to confidence? I've found that evaluating your mindset and looking at documentation differently can actually make it more meaningful. And that is the operative word for therapists...

Meaningful.

One of my taglines is "Learn to love your paperwork." People often ask me if this is really possible or laugh at the perceived absurdity. I had one person ask me, "Do you REALLY love paperwork?" The honest answer is, it depends. 

Do I love paperwork for the sake of paperwork? Do I love checking off boxes, crossing t's and dotting i's? Do I love poring through mounds of legal documents that are difficult to understand and relate to what I do? Absolutely not!

However, I do love reading the story of someone making a breakthrough. I love writing quotes from clients who have just made an impactful insight. I love writing a report or letter that someone needs in order to access a life-changing service. I also love the feeling of finishing a document I am confident will support me in case questions come up later. 

But how do you go from that place of resenting paperwork and across the bridge to "loving" paperwork? I've found that bridge is Reflection. Taking even 2-5 minutes before writing a clinical note can make all the difference. That time to really focus on the meaning of your session and the clinical outcome gives the paperwork associated with it the value it deserves.

And let's take that even further... what if we viewed our informed consent document not as a required form that needs everyone's signature but as a way to empower our clients and introduce them to parameters of the therapeutic relationship? Because that's the meaning behind an informed consent form. 

Unfortunately, though, many of us have turned these documents into legally required paperwork that we resent and then overlook... and that leads our clients to overlook these things as well. But we have the paper to change that simply with our intention. You can use a Contract for Services or Informed Consent to discuss with your clients the importance and uniqueness of the relationship you'll build over time. 

Doesn't that sound awesome? Imagine if throughout your day documentation was just a reflection of the clinical work you're doing, rather than something disconnected from it! It is possible, it just takes intention. I challenge you to be mindful of this for the next week and be open to the possibility that paperwork can have new meaning. 

And if you're looking for more ways to implement meaning into your documentation, sign up for my free crash course. In it I provide a training on what I call Meaningful Templates, a way to implement these practices more directly into your note writing. 

Now decide on one way you can focus on making paperwork more meaningful in your work. Share below and get support from your colleagues... and happy writing! 

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