Practical Tips for Easy Case Notes

This week's post is a little different because I'm sharing with you my very first podcast interview! I had a blast talking with Dr. Melvin Varghese from the Selling the Couch Podcast. We talked about intake sessions, building rapport with clients, mindset shifts in documentation and I also shared one of the notes templates I created. 

Click here to listen or download the podcast now.

In my Private Practice Paperwork Crash Course I go over four different templates therapists can use for case notes. I also share my own templates, which I call Meaningful Templates. If you haven't signed up for the free course yet, click here to get it.

When talking with Melvin I shared one of these Meaningful Templates, one called Results-based Notes. For these type of notes, the template is based on reflective questions you ask yourself as you write the note:

  1. What did my client identify as their goal originally (in the first session)?
  2. What would my client say is their current goal and how does that relate to their original goal?
  3. How did we work toward those goals today?

Use these questions to answer how the session was focused. Try answering each related to both your client's involvement as well as your own involvement in the session. 

This format makes writing notes feel very natural while keeping the note focused on the important information to have documented. You can also couple it with a more traditional note template but use the questions as a reflective exercise to prompt yourself while doing case notes. 

As mentioned in the interview with Melvin, I always recommend that you take a couple minutes to calm or center yourself before writing notes. Visualize your client leaving the session and consider what they've learned, how they feel and what actions they might take as a result of the session. 

This makes writing notes feel much more like what it should be- a clinical extension of the session. It's no longer an unrelated task, just "paperwork." 

Try it out over the next week and let me know how it goes! Leave a comment below with your experience and any adjustments you made that you found helpful. And as always, happy writing!