At this point I've talked with hundreds of therapists about one topic in particular- writing notes. And I hear some pretty common concerns...
"I feel like I always write too much but I don't know what parts to take out."
"I don't know if I'm including the right information."
"I feel like I spend too much time on writing notes."
Relate to any of these? I've found it's totally normal to have these concerns. And if you think about it, they make sense!
If you're a licensed therapist you may never have another professional read your notes. Even if you're not licensed, I've found that most therapists receive very little training and review from their supervisors.
While I do recommend connecting with other therapists to do chart reviews or at least discuss these issues (more on that in the next post), the quickest solution to this problem is knowing how to do a notes review yourself.
So let's break it down in a few easy steps:
Set aside an hour of time to review notes. Any more time and it will feel like a chore and make you overwhelmed but you want to include enough time to do a good review.
Start with one client file and go all the way back to that first intake note. Read through the notes chronologically from oldest to newest. Tip: If this is a long-term client, just go back the last six months or so.
We'll start with each individual note first. Ask yourself the following questions with each note. I recommend having the questions in front of you so they're easier to remember:
- Did I describe my own actions (or interventions) during the session?
Is my client’s response clear via quotes, observations or an assessment of what transpired?
Do I follow up on plans identified in each note?
After that is complete, answer the following questions about the entire file. The key is to make sure all the notes combine to make a clear story.
Do my notes provide a clear reason for my client initially entering treatment?
Do my notes provide a clear story of this client’s progress over time?
Do I have a note for every date of service provided and explain gaps in treatment (like vacations or missed sessions)?
And there you go... you're now a quality assurance pro!
I know it may be a little easier to have something in hand or on the screen to view, so I created a neat little handout you can download and print! Yup, you're welcome.
Your next question may be "But what if I find something is missing? How do I fix it?" Have no fear, the blog is here! Click here to read my article on fixing your notes after the fact.
Still looking for a little more help with your paperwork? Make sure you're signed up for my Love Your Paperwork Challenge. It's two weeks of daily actions to make your paperwork awesome. And it's pretty epic, if I do say so myself.
Please comment below and let me know if Handout helped and share any other tips you have. Happy reviewing!