How to Conquer Mt. Documentation (and come out even stronger than before)

ethics progress notes May 03, 2015

Documentation is scary for a lot of therapists... not like creepy clown jumping out at you scary but like going to an interview feeling totally unprepared scary. We tend to avoid talking about it unless something terribly earth-shattering has happened... like a subpoena... or a request for records from social security. 

Psst... FYI, I'm being facetious here, even subpoenas and records requests don't have to be scary.

Counselors have enough to worry about in their practice, they don't need to stay up late worrying about having their records reviewed. But how do we overcome this fear? Well, by being prepared, that's how! 

And it doesn't even have to be that difficult. The answer is much more simple than you'd think- get help from other therapists! If you're used to having your documentation reviewed by other professionals or you have colleagues with whom you feel comfortable discussing it then the task of documentation isn't nearly as scary. 

However, when we only write notes on our own and those notes never see the light of day the whole process becomes much more secretive. And secrets breed fear and insecurity. 

You may be thinking, "Well, yeah, that's sounds great but I can't just have someone come over and read all my notes." Actually, most ethical guidelines do allow for peer review of records. You could actually work with even just one colleague and review one another's work for the purposes of feedback and discussing treatment efficacy.

However, many therapists are still not comfortable with this informal type of arrangement. There is still hope! You can join a consultation group and discuss a hypothetical case. Talk about what you think would be important to document. Even write a case note for the hypothetical client and share your notes with one another. You'll get to see how everyone's style is a bit different and I guarantee you'll learn something.

The key to conquering any mountain is the support you have along the way, so don't forget that your colleagues are around to help you with ALL aspects of your clinical work, even documentation.

And if you're not quite sure where to begin, you can check out my Private Practice Paperwork Crash Course or my Meaningful Documentation Academy. Both of these programs provide strategies for climbing Mt. Documentation, giving therapists the tools they need to conquer it and provide tons of encouragement along the way. My goal is that all therapists are able to conquer their fear and find joy at the summit. 

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