I recently took to the Blissful Practice Facebook Group for some advice on documentation from those in the trenches... you! It was great to see all the tips everyone put together and also highlights that it is so important to find the paperwork practices that are meaningful to you.
Here is some of the great information I collected from this fabulous group of therapists:
Use an Electronic Health Record (EHR)
Alicia Taverner, Owner of Rancho Counseling, and Sandy Demopoulos both say that using an electronic health record (EHR) has been instrumental in improving everything related to documentation. Alicia uses Simple Practice and is able to dictate case notes on her phone using the app, which helps her stay up to date. She notes it is a "game changer." Sandy uses Counsol, which offers many features, including virtual therapy rooms.
Stay On Top Of Notes with Productivity Hacks
To help keep up with notes, Charlotte Hiler Easley schedules 30 minutes in between client sessions. That way she has time for self-care and notes. Jane Johnson Wall uses TheraNest, which helps her stay up on billing. She says this is one of the most important things to keep in mind because it is so easy to get backed up and that can result in lost revenue and lots of headaches!
Shanna of Happy Nest Therapy has also made a point to stay on top of notes. She says she created a schedule and a note template early on and this was hugely impactful. Since she took the time to make this a habit in the beginning of her private practice, she is now always able to keep up with notes, writing notes within 24 hours of every session. She also keeps a call log and reviews that each month to insure she is documenting everything outside of regular sessions.
Erin Gibb also created a note template based on common things she wrote and then takes some notes during session. She then sets a timer for five minutes after each session and makes sure to only spend that amount of time on her notes. That way she is done quickly but she is keeping the quality content.
And Raquel Buchanan, also of Rancho Counseling, adds that she notices many clinicians fall behind because they are not ending sessions on time. She sticks to a 50 minute session, then 10 minutes of note writing. Raquel also notes that you can use this additional time write notes with your client, too.
You can also write intakes with your client during the first session, as Traci Lowenthal of Creative Insights Counseling does. She says this has been "miraculous" for keeping her up to date with bigger paperwork tasks. And when she gets behind on things like notes, Traci sets a timer for 20 minutes 1-2 times a day to make sure she is working to catch up.
Document the Little Things
Nicol Stolar-Peterson of Therapist Court Prep recommends two tips based on her experience as an expert witness who is often testifying in court: 1) Document your client's appearance, including what they wear. This way you are able to quickly and objectively note an changes that occur over time. 2) Time stamp everything. Document and time stamp when clients disclose new or significant information, when they sign or ask about documents or policies, etc. She notes that "once I start giving the exact times of disclosures, I find that attorneys back off quite a bit."
Use Your Experience as a Resource
Tiffanie Trudeau of Counseling Alliance is a former Clinical Director at an agency. When she opened her private practice she decided rather than give in to the temptation of forgoing all the agency documentation, she would take that foundation and use it in her practice. She is consistent with her paperwork practices, whether her client is pro bono, insurance or private pay. She even used one of my favorite quotes in her advice: "if you didn't write it down, it didn't happen."
On the flip side, Shirani Pathak of the Relationship Center of Silicon Valley recommends keeping things simple. Maintaining her previous agency's standards was difficult in private practice and so she made time to whittle down to just the necessities. Now she is confident that she's meeting ethical standards but it is also easy for her to keep up with everything.
Being on top of things is even more important as you start to supervise others. Group practice owner and coach Sherry Shockey-Pope recommends documenting when you discuss cases with supervisees. Write down your discussion and then your follow up plan with the client... and then actually follow up!
Communicate With Your Clients
Similarly, Kate Pieper says that clients have commented on her follow up with them. She makes sure to note at the end of each session what they will be addressing in the next session. Kate also recommends not being afraid to take some notes during counseling sessions. She is casual with this and that makes her clients feel comfortable, too.
Maaliea Wilbur of Therapy Works wraps things up nicely with this advice: "Do it!"
Lastly, Amber Hawley of Fremont Counseling Services has one last tip for you... sign up for my Webinar CE Club! (Edit: the Webinar CE Club is no longer, but you still get access to all my ote writing tips and trainings in the Meaningful Documentation Academy!) I swear, I didn't tell her to say that ;) But it does highlight the importance of staying connected with colleagues and making room for this type of discussion so that you can always have the best resources.
Feel free to share your tips below in the comments!