You’ve maybe heard me talk (or really, write) about feelings and documentation before… I like to normalize a lot of what I hear from therapists. Because I hear it ALL THE TIME.
"I don’t know if I’m writing notes the “right” way."
"I hate writing notes and avoid it but then I get backed up."
Well, in this post I’ve got a tool for you to dig a little deeper and see what it is that’s really causing problems with your notes… and what it is you’re doing well already.
Check out the questions below. They’re all really simple yes/no questions related to how you write notes. No one else is watching so be honest with yourself! And if you want a pretty version to download, click here.
When I sit down to write notes I know exactly what to say.
I know how to calm my mind when my thoughts are racing.
When I think about writing notes I feel calm and confident.
I can easily put into words what “progress” looks like for my clients.
If a client asked to see their records, I would feel comfortable letting them read my notes.
I know how long it takes me to write a case note.
I know what time of day is best for me to reflect and be quiet.
First, let’s analyze what it was like completing the quiz…
What triggered you emotionally? Was there a question that elicited fear, guilt, resentment, anxiety? Take a moment to write down what those feelings are and why.
Acknowledge any prior negative experiences with documentation. Lots of therapists tell me they’ve had a bad experience with a prior supervisor or with having records examined by insurance or requested from a client. That’s okay and it doesn’t have to dictate how you feel about writing notes from now on.
Now let’s check out your answers. Obviously, we’re looking for “yes” answers to all (or at least most) of the above questions.
Was there an area in which you felt confident? What questions were a clear yes? Those are your strengths related to documentation.
And the no’s… are they mostly emotional or logistical? Some people feel okay about their documentation but they need to get the logistics of creating time for writing notes improved. They know what they’re doing for the most part but tend to fall behind easily and then get overwhelmed by the sheer volume.
Others may have a clear idea of the general time it takes and be diligent about writing notes regularly but notes still produce a feeling of anxiety or resentment. You may not feel confident that the content is “up to par” or feel unclear about what should and shouldn’t be included.
Once you have a clearer idea of where to focus your energy (and what to keep doing well) you can take steps to improve it.
Want someone to help you write some notes and actually review them? Schedule a time with a colleague or check out my individual consultation services.
Looking for examples of different types of notes to write? Sign up for my (free) Private Practice Paperwork Crash Course to learn about four different templates to use for notes and see some examples.
Go through your “no” answers and choose just one to work on. See what resources are best suited for that and then take action! There’s no better time to improve your notes than now!!
What’s your next step? Leave a comment below so we can follow up :)