We all know completely ignoring documentation is probably a bad thing, right? And honestly, most therapists don't completely ignore their paperwork (although believe me, there are SOME that actually do!). It's not really that difficult, right? Can't you just copy some forms from an old supervisor, slap on your own logo and address, grab a notepad and some manila folders and get going?
Well, yes and no. You could do what's described above. And you know what, you might be just fine... for thirty or forty years, even. Or you might be in some serious trouble.
Before we get into the "serious trouble" part let me reiterate that I am NOT into fear-based thinking related to documentation. I'm not trying to scare you or create anxiety; I want to do the opposite. So, let's talk about possible trouble spots and how to avoid them for good...
We'll start with policies and procedures. When you copy from someone else, even a great supervisor or a form you purchased, you lose the personal aspect of you. I'm all about checking out samples and using templates to make life easier. However, don't just swap out someone else's name for your name!
Read through it. Do these policies make sense for you? For the clients you see? Anything you tend to do differently or always wondered if you could do differently? Then CHANGE IT. Make it meaningful to your practice.
Some therapists have a lawyer check out their policies to make sure everything is on the up and up. I think that's a great idea, but again, make sure the "youness" of your practice doesn't get lost in the shuffle. Can you actually understand what the forms say? If not, go back and change the wording. If you can't understand it, your clients sure as heck won't understand it. And you need to know your forms and policies really well so you explain them to clients and reference them when needed.
So, three months into treatment, when your client brings up something about payment, missing or rescheduling a session, or wanting to reach out to you via Twitter... you'll be ready! You'll have already reviewed the policies with them so you can offer a friendly reminder... and you can do that ever so gracefully and easily because these are policies that you know, that make sense for everything you do.
Which leads me to my next topic- keeping records. While it may seem easy and appealing to just throw some papers in a manila folder, there's a lot more to think about when it comes to storing records. You've just started a long-term relationship with your documentation. That's right, even if your client breaks up with you... you get to keep custody of the records!
Each discipline and state has different guidelines but the common consensus is seven years for adults and for minors, 3-7 years after they turn 18. In other words- a long frickin' time!
That means it pays to pause and think about HOW you want to keep records long term... from the beginning. I encourage therapists to keep records electronically because it's much easier to store for years. And it doesn't matter if you move offices, states, whatever. If you want help searching for a good electronic record system, check out Eileen at EHRassist for some helpful tips.
But even if electronic records aren't your thing, you can still make sure to do your records right without things getting complicated...
Think about where you want your forms to go and stick to a specific order in every client file.
Make sure everything is properly secured in the file so you don't lose papers (I cannot tell you how often I've seen this simple mistake!).
Keep things in order by year and name so you can easily search later on.
And make sure you stick to a schedule for writing notes so you know things are up to date.
And that brings us to the topic about which I'm asked most! Writing notes. Therapists tend to worry about their notes a lot... And to worry in solitude.
You don't know if your notes are sufficient or too long or whether or not they even make sense. Maybe you worry you share too much. But you have no clue what to do about it because you're not going to bring confidential notes to a networking meeting and ask about it there!
Unfortunately, this means most Counselors then choose to ignore the nagging questions and live with the ambiguity without seeking more guidance. That leads to a lot of ongoing anxiety around documentation and especially leads to panic mode when a request for records or a subpoena shows up.
My solution? Share and ask! You need a community of therapists you can go to with complex questions. That may be a consultation group you meet with or someone you can call on the phone.
I also recommend doing a note writing exercise with other therapists. In my Meaningful Documentation program we review a mock session and then everyone writes a note about the session. We all get to see the different styles, share ideas, get confirmation we're doing the "right thing" and with no concerns about sharing client information!
I've used this exercise a few times with therapists in person and it's usually a little nerve-wracking for people in the beginning. They want to avoid it, like they're used to doing. But once I persuade a few brave souls that there's no judgment and everyone else is just as terrified, they step up.
They choose to take a chance, to learn and grow as a clinician. And they feel so good about it afterwards! The whole room changes from uncomfortable anxiety to calm.
Thats why I love training and why I choose to focus on this topic of documentation. You don't have to ignore it and you don't have to live in fear.
Enrollment in my Meaningful Documentation program is closing tonight. Click here to learn more or to sign up for information on the next round.