Do you ever find yourself saying the same thing over and over again? I talk with hundreds of therapists and I certainly find myself sharing the same pieces of advice each month.
So what better use of a blog than to write down those most commonly given tips on writing notes?! Below are my most common answers when presented with various problems or questions related to notes...
Choose a theme for the session
Take a moment to think about the main topic you and your client (or clients) reviewed in the session. You may have jumped around to a few different things but don't focus on the minor details. Stick with the general theme and leave the rest out!
Note: Of course, any time there are safety concerns, this rule goes out the window and you want to carefully document your actions.
Create a regular schedule
Many therapists think they'll squeeze in a few notes between sessions or randomly complete them throughout the week. Ever hear that saying "Fail to plan and plan to fail"... yeah, that totally applies here. Make sure you have time to do your notes that is separate from time you plan to spend on other administrative tasks (like answering emails and phone calls).
And make your schedule realistic. Do the math to see how much time you'll need. For example, if you see 15 clients per week and spend about 10 minutes per note that is 2.5 hours you should plan to spend each week on notes.
That's pretty reasonable for most people... but if the thought of spending two and a half hours (or more) on notes each week for the rest of your career makes you want to throw up, consider checking out collaborative documentation for at least some of your clients. You have options, but make sure you figure out what works best for you so you can be successful.
Simplify your template
Many therapists start out in private practice using all the documentation techniques their previous supervisor used. But (a lot of the time) that doesn't work out so well. I'm assuming you started a private practice to have some freedom in the way you do therapy and guess what, that applies to your notes, too!
Choose a simple template you can use with all your clients and stick to it. If you want to try out a few different ones, I recommend staying consistent for at least 1-2 weeks to see if you like it. Once you get the hang of writing the same way consistently, you'll have to think about your notes less. They'll start to flow.
If you want some tutoring on various templates and how to use them, check out my free Private Practice Paperwork Crash Course. I go through four different templates- DAP, GIRP, PAIP and SOAP.
Wait on using check boxes
This is a biggie. Lots of counselors ask me for check boxes, how to create notes with check boxes, lists of interventions, etc. The thing is, I could give you a list with hundreds of options but that would just be overwhelming. And there's no way I can personalize something like that for you without first evaluating quite a few of your notes, your therapy style and getting a sense of your typical client.
So my recommendation is to create the easy template with check boxes later. First, write your notes using a sentence structure and one of the templates described earlier. Then, after you've been in practice for 6-12 months, evaluate all your notes and pick out the common interventions you provide. You can do this exercise in about an hour.
Do that and you'll have a very personalized list that will truly save you time, rather than searching through some pre-made template where half the options don't apply to you. You can click here to watch my interview with Rajani Levis, a therapist in San Francisco who used this method to create her own notes template.
Be wary of taking "quick notes"
Many therapists fall into the trap of jotting down a few quick notes to themselves at the end of a session, with the intention to write the full note later, tomorrow, etc. It seems like a good idea initially because you're making sure you don't forget something, knowing you don't have time to write the note at this moment... but this actually creates a false sense of security.
What commonly happens is the therapist holds off on writing notes, thinking they've got everything covered. Then the pile snowballs and five months later they have hundreds of notes to write (yes, literally... this happens a A LOT).
Obviously, no one wants to end up in the same situation without the quickie notes to remind them of what actually happened three months ago in that one session with so and so. But I have a theory that most therapists who get behind never would have let themselves get to that point if they didn't have those notes as a "safety net."
Seriously, if you follow these five tips you will find yourself avoiding many of the problems counselors commonly run into.
"Did she just say commonly run into?" Yup, I did! Because most therapists do fall behind on their notes at some point. And most therapists feel insecure about their note writing skills.
My personal mission is to change all that, for good! I want to make sure we all have the support we need to succeed.
That's why I created the free Private Practice Paperwork Crash Course, write weekly blogs, do monthly webinars (found in the Meaningful Documentation Academy) and all kinds of other things... to eventually replace this fear of documentation with confidence and, dare I say... excitement!
You can also learn more about writing notes (and get 2 NBCC approved CE credits) through my workshop The Counselor's Guide to Writing Notes** or learn some great tips from my ebook Workflow Therapy: Time Management and Simple Systems for Counselor's.
It's a journey, a process, and I'm here with you for the long haul. So make sure you share these resources and let's keep encouraging one another whenever we can.
Until next time, happy writing!
**The Counselor's Guide to Writing Notes is now exclusively available through the Meaningful Documentation Academy.