I've seen some pretty crazy stuff in client files... like, pretty bad! But you know what's most surprising about finding those things?
In most cases the therapist had no clue their documentation was a mess.
We're talking like, 99% of the time here. That's not to say they didn't feel a little hesitant. And most of them really disliked doing paperwork. But they had no idea what they were doing made their documentation look so bad.
So I thought I'd share with you some things I've noticed after reviewing hundreds of client files...
The sequence of documentation is super important.
A client's file should tell a clear story. You may have heard that before but let's really look at what this means.
Most therapists have everything in sections and it's all in a vacuum. The administrative paperwork here. The notes there. Some other random stuff after that. Maybe a treatment plan thrown in the middle.
But what if we put it all together as one story? It's all about looking at the file from intake to where you are right now.
Those initial conversations (your intake and administrative paperwork) led into a treatment plan which led into notes about how you're actually working on that treatment plan. And that leads in to revisions as needed until you have closing paperwork.
It creates a smooth, easy flow... like calm waves. It's not choppy and chaotic.
Treatment plans, write them out at least a little.
A lot of counselors have a wonderful plan for treatment... in their head. But they never put it down on paper. I talk about some reasons why here in this blog post.
Writing it out (even just a couple of sentences) can make a huge impact, for a lot of reasons. It helps keep you on track. It helps you and your client evaluate what's working. And if you bill insurance, it lets them know you're meeting medical necessity guidelines (read more about that here).
Keep your focus on the important things.
When you're writing notes, leave out all the extraneous info (getting people water, the nitty gritty details of a story the client told). Keep it simple and focused. Try keeping each section down to 2-3 sentences.
Unless you had a crisis session, there really shouldn't be much more than that. Focus on what you did and how your client responded. Note anything that stuck out to you as important or odd. Include the next time you'll see your client.
And leave it at that.
Review your charts from a storytelling perspective.
A lot of times what I see in client files doesn't make sense. It takes me a long time to review because the story is disjointed. I need to flip back and forth. Or something is missing and I keep searching to find it.
It takes me a loooooonnnng time to review a messy chart.
However, when a file reads like a story it's so much easier to review. One day flows in to the next and there aren't any big surprises. The interpretation matches the objective info presented and I can clearly see what the therapist is thinking.
I encourage you to go through one of your client's files this week. View it as a story. Does it make sense chronologically? Are there any missing pieces? Do your interpretations make sense with what is presented by the client?
And is it easy to read?
Then head back over here and let us know how it goes! And if you haven't already done so, sign up for my weekly newsletter where I send special tips and resources to help you along the documentation journey.
Cleaning up a mess is much easier with help, so don't be afraid to ask for it! Happy writing :)