By far, the most common concern presented to me by therapists is note quality. Clinicians are hoping their notes are good, but since no one else reads them or since they receive little training in this area, they actually have no idea if the quality is there.
For content related to writing, I've got sample notes available for free inside my Private Practice Paperwork Crash Course. You can also check out this blog post that has an example of necessary content and how to pare down note length.
Today I'm sharing with you five counterintuitive strategies that will help you improve your notes, no matter what your current quality may be... and they're all things you can try out right away!
1) Take a break
One of the best things you can do for your productivity is to take regular breaks. Whether it's five minutes every half hour, 10 minutes every hour it doesn't matter. The key is that you must schedule them in and take them!
Even if you feel like you're in a place of "flow" and working for over an hour, it is rarely helpful to continue working without a break. Trust me, as someone with ADHD, I know this struggle!
Lucky for you, I've made it a little easier to take a quick five minute break. Why not listen to some music that will help you rock out, give you a dance break, or pump you up for more work? Check out my new playlist on YouTube for some epic songs to keep you going... after a break to rock out or dance:
2) Reflect first
Taking the time to reflect on your session, your client's progress to date, any struggles you're encountering, etc. will clear your head and help you focus when writing your notes. It doesn't have to be long but pause for 1-2 minutes before your note and make sure you are in the right head space.
3) Plan ahead
You've heard that quote: "Fail to plan and plan to fail." That definitely applies to your notes! Make sure you give yourself enough time to write notes each day, allowing time for other administrative tasks at a different time of day.
Many counselors run into trouble because they forget to plan out note writing time when figuring out their schedule. Even then, they'll often add that time for general administrative tasks including notes. Doing this usually means notes become a last priority, behind answering voicemails and emails.
4) Read through old notes
I recommend you spend time each quarter looking through your client's file. This will actually make you a better writer because you'll catch things you may have missed or recognize common phrases you like to use in notes.
This review time will also help you see how well you're able to blend sessions together to tell the complete journey your client is taking with you. Don't worry about spending hours on this. Simply plan for one hour each quarter and see your notes grow in quality!
5) Let your client help
Lastly, let your client help you write notes! Collaborative documentation has not only shown to be a faster way to write notes, but clinicians commonly report it also helps improve their note quality. They feel better about the content because it is up to date and their client has helped summarize things from session.
Plus, if your client is contributing to their notes each week, the fear of your client seeing their records is pretty much eliminated. ;)
If you'd like a more in-depth training related to collaborative documentation, consider signing up for my Meaningful Documentation Academy. There are already four previous trainings waiting to be viewed, one of them on how to incorporate collaborative documentation. You'll also get access to a new webinar (and CE credits!) each month.
Which of these strategies is the most helpful for you? Which one do you plan to try out this week? Let me know in the comments below!