Unfortunately, when a lot of therapists come to me they come from a place of fear. They're nervous about the harm their documentation could cause them rather than focused on the benefits of writing rock solid clinical notes. Documentation then becomes more than just a burden, it becomes an anxiety-provoking and almost punitive task.
My goal is to help counselors see that documentation is a part of good clinical care and it doesn't have to be boring or scary. Here are three of the big concerns I hear from therapists and some ways to combat your related fears.
Writing notes is a very private thing because of client confidentiality. Unfortunately, this ends up making the process pretty mysterious to therapists in private practice. We don't talk about it much and then we never know what our colleagues are doing. We're left to assume we must be doing it correctly... or worry we're doing it incorrectly.
Let me tell you a secret- as long as you're actually writing notes on your sessions, you're probably doing it "the right way"! In my free Crash Course I talk about some standard templates you can use that prompt you to cover generally accepted areas and help you write top notch notes. You can also check out your profession's ethical guidelines to determine specific things that should be in every note (things like client name, date, time of session, etc.).
Another way to test the quality of your notes is to have another professional do a review for you. I recommend teaming up with someone once a year and swapping charts to do a quality review. This gives you an objective opinion about how you're capturing the story of your client's journey with you. And that will help prepare you for the next big fear a lot of therapists have...
I hear this a lot and there is some truth to this one. Lawyers often have a way of manipulating words to mean something very different than originally intended. However, I stand firm in my belief that you're more likely to regret writing too little than writing too much.
Documentation is black and white, signed and sealed. Memory is not. I would much rather put my documentation in the hands of a lawyer than my memory (or my client's memory). Without good notes, any argument becomes "he said, she said" because if it's not written down, it didn't happen.
I can't guarantee a lawyer will never use your documentation in a way other than you intended. However, I can guarantee that you will regret limiting your documentation to the bare minimum in the event you need it to support you in a court case.
This is another thing that certainly might happen, but you know what? It's not as scary as it sounds. In another post, I talk about my experience training to do utilization reviews. Insurance companies want their interaction with your documentation to be quick and easy. In all frankness, they have one main purposes- to cut costs (meaning, reduce the number of sessions to the bare minimum needed to treat the condition). They do this by ensuring that all services provided are medically necessary.
It's not that big a deal if you know the right terms to use and the purpose behind the review itself. They don't typically want to pour over your notes. Rather, they may request a copy of your treatment plan and want to talk with you about how treatment is going in order to determine if more sessions are necessary.
If you're nervous about getting on the phone with an insurance company, check out Barbara Griswold's website and free newsletter: Navigating the Insurance Maze. She'll even get on the phone with you and do a mock call as the insurance care manager.
So you see, there are plenty of resources out there to help therapists with documentation. And remember, the biggest resource is one another! I can tell you that after less than a year of consulting through QA Prep, I've learned most counselors are worried about their documentation and just feel too embarrassed to bring it up to their colleagues. But once the conversation is started, everyone realizes it's a safe thing to discuss.
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