By far, the most common thing I hear from clinicians is that they didn't receive any (or sufficient) training in documentation.
This is a topic that is very important to all of you. I know because you tell me, you read this blog, you watch the videos and I consistently hear the same thing again and again in workshops.
Since many people who are supervisors are the same counselors who never received training in documentation themselves, they often don't know where to start with their supervisees.
That's what this blog post is for!
I'm going to outline some different ways to review documentation and notes with your fellows, interns, practicum students and trainees. You may not use all of them, especially if you're new to this, but I guarantee some of these steps will give you ideas for where to start or how to improve.
1. Review files and notes every week (or however often you meet).
It can be tempting to spend time in supervision focused on the more "interesting" clinical content or to address the crisis of the week. However, your supervision time should incorporate training on ALL aspects of being a clinician.
And that includes getting paperwork done and evaluating how effective that paperwork is.
Spend some time looking through a client's file, particularly if it's a client about whom you're already discussing a crisis or clinical issue. Not only will this ensure all the legal ducks are in a row, but going back to earlier stages in treatment can often provide clinical insight now that you've spent some time with this client.
2. Read through an entire file, not just that week's notes.
This one is huge! Working as a Quality Improvement Specialist in a few different agencies, I noticed that I would often pick up on things the supervisor hadn't... even when they were regularly reading and approving weekly notes.
That's because the supervisor was focused only one note.
Looking at that note alone, it seemed fine. However, when read within the context of the client's full file (as I was reading), certain things stand out.
For example, if something significant had happened in the previous session and that session's note had identified some follow up that would happen, I was looking for that in the next note. If that follow up was missing I picked up on it right away because it made the client's story disjointed.
However, the supervisor could easily overlook this because they were simply focused on the one note and whether or not that content was coherent and professional. Not a bad thing, but taking a different approach every few weeks will provide a different context.
3. Practice together, especially in the beginning.
Do you remember writing your first case note? I do. I remember that I had a few samples in front of me and while they seemed great, they all of a sudden seemed completely irrelevant to the note I was writing. So I simply dove in and tested the waters to see what would be approved.
Now consider if my first experience writing notes had been with a supportive and experienced clinician guiding me. I would've had a chance to ask questions, compare things, get different ideas for wording, etc.
I know what you're thinking... notes are boring and no one wants to spend time together writing notes. However, I've found this to be the opposite!
One of the things people consistently mention about my trainings is that they enjoy seeing examples, watching me write notes, and writing notes together. They even really like getting feedback on the notes they've written.
However, this is something that is often nerve-wracking for people and it's unlikely anyone will ever ask you for it. You must initiate but I promise you that 99% of the time, it will go very well.
So take the time to review paperwork, practice writing things together, and continue to do these periodically throughout your supervision time, not only in the beginning or not only for people who appear to be struggling.
You will create much more confident clinicians who are able to focus on what matters most- how to best help their clients.
Now you tell us! What have you found to be helpful when working as a supervisor. What did a supervisor offer you that provided you the confidence and tools you needed to be successful? Let us know in the comments below.