Therapy Notes: Your FAQ's Answered

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Dealing with notes from months ago.

Worrying about notes sharing too much information if revealed in a legal proceeding.

Spending too much time writing notes because of worries about insurance audits.

These are the concerns many counselors share about their case notes. 

I've been collecting a database of questions I commonly receive and figured it's about time I focused on answering some of these! So, this will be the first blog in a series focused on FAQ's. 

Remember that my goal is never to tell you exactly how to do something. I am a strong believer in multiple correct answers or ways of doing things (in most circumstances). But I do hope to offer you some food for thought in my answers below.

These are all real questions or concerns brought up by other therapists... and I hear them over and over again:

 

Writing Notes Late

"How late can I write notes if I'm behind?"

You can (and I would say, should) write any note that isn't written. That means if the note is from last year, write it! If it's from last month, write it! There is no expiration date on writing notes.

Now, if you're like me, there may be an "expiration date" for your memory. And there are certainly expiration dates for things like insurance claims, so that's another story. But having a complete story in your client's record is always important. 

I do recommend that if it's been a long time (this is subjective but let's say more than a month), include something like "Late Entry" at the top of your note. 

You're not trying to hide anything and since you should sign and date all notes on the date of entry, that won't match your session date. This is simply providing an explanation for why those dates are off.

 

"What can I do if too much time has passed since the session and I don't remember anything to write as a note?"

Sometimes this happens. And it sucks. 

Do what you can but NEVER make up information that you don't remember. 

If you honestly can't remember what happened but you're certain your client did show up for the session, write a very brief note like...

Late Entry. Client attended session. Addressed treatment goals. Next session planned for xx/yy/zz.

Is that a good note? Of course not. But let me tell you, it's still better than no note at all and you're not compromising your integrity. Admit that the situation sucks, create a plan so it doesn't happen again, and move on. 

 

How Much To Include In Notes

"I feel I write too much... that is how I remember things actually. Should I then do a summary for the legal notes?"

I feel the same way! As I've mentioned before, part of the reason I stay on top of notes is that I know I have a horrible memory and won't be able to write them a week later if I got behind. 

I recommend asking yourself some key questions while writing:

What was the theme of our session?

What stood out to me as important about our session? 

What seemed important to my client during our session?

What do I want to follow up on? 

What do I think will be really important to have written down for later?

Try to keep your answer to each of those questions to one sentence, then use that as the basis for what you include in your notes. This process may take a little more time initially, but you'll be able to train yourself to think about these things when you sit down to write notes.

The process will get easier and faster over time. And you know what? You may simply write a little more in your notes than another therapist. And that's okay.

And if writing a lot or taking a lot of time on notes is a concern for you, I actually don't recommend you write a summary for the "legal" notes. (This would mean writing freely as process notes and then writing a summary for the progress notes- see the section  on HIPAA below for the difference.)

Why is that? Because then you'll create more stress for yourself and spend even more time on notes! Not what we're going for here. Simplify things instead.

It's okay to have objective information in your notes. We worry a little too much about having "too much information" in our progress notes. But if you want some more guidance on how to pare things down, check out this blog post where I give an example of how to do that.

 

"How much specific detail do you include regarding session details and/or thought process in how you arrived at a decision?"

Here's a vague answer you'll hate- however much it takes to explain your rationale.

Seriously though, if you're in a situation where you're documenting why you made a clinical decision, you're likely dealing with something that could potentially be high risk or an ethical dilemma or the like. This is NOT the time to skimp on information!

Provide the applicable laws or ethical principles, information from research or consultations you did, and how all of those things contributed to your decision. This is the basis for your rationale. 

Sometimes this can be accomplished in 1-2 sentences, sometimes it will take 1-2 paragraphs. It simply depends on the situation. 

 

Insurance Worries

"I'm finding myself writing 1-2 page progress notes. Since I've started taking insurance, I've become stressed with note taking."

Notes for clients using most insurance companies aren't drastically different from notes for clients who pay privately. The biggest difference with insurance is that you want to consider medical necessity. 

I have a much more detailed blog post on this topic here, but I can summarize by saying that you do want to make sure you're following a treatment plan that is focused on the client's diagnosis and you want to address two things in every note:

  1. Progress made
  2. Ongoing need

This is the fine line with insurance. If therapy isn't helping your client in the long-term, they may choose to no longer pay or not to approve further sessions. However, if you only focus on progress then it appears your client no longer needs services.

Insurance is often not concerned about your specific interventions or treatment modality (although it does apply in some cases). They simply want to see that they are paying for a service that is meeting the member's needs. 

And yes, they usually do want to see how they can do that more cheaply. Let's be real. 

So make sure you consider that, too. How is ongoing therapy keeping your client from deteriorating, from needing more intensive treatment? How is it improving their health or relationships? These are all things that make therapy a very cost-effective treatment when compared to things like hospitalization or tests for somatic presentations of symptoms. 

 

"How to document in a problem focused way to satisfy insurance, disability, etc when the session is strength based and optimistic."

Continuing our discussion from the answer above, you want to include honest information about the progress (or lack therof) that your client is making, as well as their ongoing need. 

I definitely work from a strengths-based perspective, but that doesn't mean I'm ignorant to the reason my client is seeking therapy.

They have a concern and that manifests itself in ways that are impacting them negatively. To gloss over this or pretend it's not a concern is actually quite demeaning, disempowering and invalidating.

Documenting this and addressing it is a critical component of enacting change and working through any problem. Documenting this does not place blame on the client or invalidate any of their strengths. In fact, it does quite the opposite.

So yes, include the strengths and the wins. Absolutely. 

And then also include what continues to be a concern, a problem, a need. Identify what didn't work or continues to be a struggle. Document the full journey your client is on and you'll have a beautiful narrative that highlights their resiliency and strength throughout. 

 

HIPAA & Psychotherapy Notes

"What are psychotherapy notes based on HIPAA?"

This is a BIG topic and for a more complete answer, I'll direct you here to an article from Simple Practice's blog. But here are the basics with psychotherapy notes per HIPAA...

  1. Psychotherapy notes are what we commonly refer to as process notes.
  2. Psychotherapy notes are optional and MUST be kept separate from the client record to receive their distinction.
  3. Psychotherapy notes are NOT progress notes (case notes) that discuss ongoing treatment.

Why they decided to use such a confusing term, I'll never know! But per HIPAA, psychotherapy notes are those optional notes you might write to yourself about sessions, clients, to jog your memory, etc. As such, they receive special privacy and clients are typically not entitled to them. 

However, these never take the place of progress notes, which are the ethically and legally required notes we do need to take. 

So yes, if you choose to write process/psychotherapy notes, you are choosing to write two different notes for sessions. For some therapists, this is a really important part of their own process. For others, it is simply an extra burden and they choose not to do it. 

In case you're wondering, no, I don't write process notes. But I also share notes with my clients on a regular basis, so I often do things a little differently ;) 

 

"It appears that process notes can also be subpoenaed. How do we keep non clinical notes for our memory sake?"

Yes, they can! It is a common misconception that process notes (psychotherapy notes as discussed in the previous question) receive such special treatment they cannot be subpoenaed. 

However, it is very rare that psychotherapy notes are ever subpoenaed and I would guess that if they are, whomever is requesting them is often intending to request progress notes instead. It is always best to call your client and discuss the reason for the subpoena, see if they are providing consent to release records, and to then assert privilege when applicable. 

Unfortunately, since the definition of psychotherapy notes is basically any notes you take about clinical treatment for your own purposes, I can't think of a way to ethically do that so they are never potentially subpoenaed. 

Remember though, that process notes can be whatever you want them to be. That means you can use abbreviations, shorthand, your own illegible handwriting... whatever you want! You do not have to worry about these notes being ready for scrutiny. 

That being said, the one thing I would encourage you to consider is how your client may react if they saw the notes. Although it is highly unlikely that will ever happen, you wouldn't want to have anything that could be offensive. I'm not saying to avoid writing things that are true, but do consider how you word things. 

 

What do you think about these situations? You may have another great suggestion or factor to consider. Let us know in the comments!

The Comprehensive Note Writing Guide for Therapists

I've written quite a few blog posts on notes over the past few years. Side note: In case you're feeling overwhelmed by the thought of blogging or starting something new, I never thought I'd have this much written by now! Keep at it and be consistent :)

Anyway... I wanted to put what I consider some of my best tips for writing notes all in one easy-to-find spot. Below are articles I've written here on QA Prep, as well as some other gems I've written for other people's sites. 

See what applies to you and check out the related article. Notice something you'd like to work on at some point in the future? Schedule it in your calendar now and bookmark this page so you can follow up when you have time to focus

Reviewing and improving your notes is an ongoing process. Don't feel like you have to do it all at once or learn everything right away. But if you don't schedule it and make that a priority, it's likely one of those things that will fall by the wayside. So take 30 seconds to schedule that time right now.

Let's dive in...

Questions to ask yourself when writing notes

It's always nice to have some guidance when sitting down to write notes. In this article I outline four questions you can post somewhere to ask yourself before writing notes. This helps to put you in the right mindset and keep the content something you can be proud of. 

Consider who may read your notes

There are actually many people who could potentially read your client's case notes. In this article I review the three people who are most likely to do so and how to consider what each may be looking for. 

Create your own notes template with check boxes

A lot of people ask me about creating check boxes for the notes in order to save time. In this article I outline a sure-fire process for doing this in a way that will still capture the individualized needs of your clients, as well as your unique ways of providing therapy.

Choose a notes template that works for you

Although I talk about some common notes templates in my free Private Practice Paperwork Crash Crash, this article gives you a quick read with similar information. I review four common notes templates and how they may apply to your counseling practice. 

Figure out how long your notes need to be

In this article I give you an example of both a short and long note and we evaluate what type of information we can remove in order to make things more efficient. This article is especially helpful if you feel like you write too much in your notes and want to cut things down.

Review your notes to see how you're doing

In this recent article I share some strategies for how to review your documentation. This is something I think is very helpful when you're feeling stuck with a client, as well as when you're ending treatment or writing summary letters. 

Write notes that make insurance companies happy

Notes don't necessarily need to be very different if you contract with insurance panels, but there are things you consistently need to think about with your documentation. In this article I outline the most important things to focus on if you think an insurance company may want to see your notes some day.

Identify ways to save time on notes

Most therapists are looking for ways to save time when writing notes. While I do encourage you to make documentation a meaningful part of the clinical process, efficiency is always a great thing! In this article I give you a variety of strategies for saving time on notes... and you can try out most of them right away.

Catch up on notes if you've gotten behind

It's a horrible feeling to get behind in your notes. Overwhelm takes over and it can be very difficult to find a way to catch up. In this article I share a five step process for catching up on notes, no matter how far behind you are!

There you have it! A comprehensive list of how to improve your notes and think about them a little differently. If you'd like more help with notes and documentation in general, you can check out my online workshop The Counselor's Guide to Writing Notes**. I love seeing how people's fear of documentation shifts after they can see some examples. 

You can also check out my ebook, Workflow Therapy: Time Management and Simple Systems for Counselors. It's a compilation of my best tips and blogs on improving your efficiency and managing all the paperwork related items in your practice.

So whether or not I see you online or in person, happy writing. 

**The Counselor's Guide to Writing Notes is now included with membership to the Meaningful Documentation Academy.

A Therapist's #1 Secret Productivity Killer

I talk with a lot of therapists who have trouble keeping up with notes. Yet, when we actually sit down to write notes together it only takes about five minutes to write one note (on average). 

Even if you see 20 clients a week, that's only an hour and 40 minutes every week to keep up with notes. If we assume a 40 hour work week, that still leaves more than 18 hours each week for all the extra administrative stuff you do (answering phone calls, marketing, billing, networking, etc.). This makes paperwork, and particularly notes, seem like a really small portion of the weekly workload, right? Especially when we consider how important your notes are for your business. 

So if it's not the time it takes to write notes themselves that's causing the problem, what is?

I've seen one problem come up over and over again... Not ending your sessions on time

Yup, this one thing is so easy to do but it eats up hours worth of productivity. Don't believe me? Let me count the ways, my friend...

Ending sessions late eats into the time you need to care for yourself. When you have clients scheduled back to back and you're not able to take some time to center yourself in between you feel more exhausted at the end of your day. It's go, go, go until the last client leaves. By the end of a day like that, the last thing you want to do is stay in your office and finish notes before heading home.

Even more practically, you may simply be hungry or tired and need to head home because it's dinner time, bedtime, take the kids to swimming lessons time, etc. 

One solution to this problem? Schedule yourself a 30 minute break in the middle of back to back sessions. Decide how best to use this time, whether it's for a walk around the block, taking a nap, grabbing a bite to eat or even catching up on a few notes. 

Now let me say that I do think it's okay to write your notes the next day. If I see clients until 8pm at night, that's what I'm doing! But the moment we put off that task we increase the likelihood that it will get pushed back even further (woops, forgot about that appointment tomorrow morning and then the kid's school thing!) and also that it will be of poorer quality whenever it does get done.

And guess what? It takes longer to write notes when you have to try and recall what actually happened in the session. I know I'm not the only one who has sat in front of a computer screen trying to remember what in the heck was that big thing I talked about in my session at 4pm two days ago. Now, a task that could take five minutes is taking fifteen minutes. And there are 10 more notes to do. 

Ending sessions late also eats into time you could spend on small tasks. One good thing about all of us being on our phones all the time is that you can actually be productive while doing things like waiting in line or sitting in the waiting room at a doctor's office.

Let's say you feel great in between sessions and don't really feel the need to center yourself, go to the bathroom or grab a quick snack. If you see 4 clients in a row and do 50 minute sessions, that's 30 minutes in between you can use to call someone back, confirm an appointment, briefly answer an email... Or even write a progress note!

By contrast, those extra 5-10 minutes you're providing your clients by going over in session aren't likely making a huge overall impact. Of course, there are always exceptions and the occasional session will go over but when this becomes a regular practice, it really takes up your time.

My whole point with using the phrase "meaningful documentation" over and over again is that your paperwork needs to suit your (and ultimately, your client's) needs. Same with your policies and procedures.

If you know you won't be ending sessions on time and don't want the stress, then own it. Plan around it. Use the 30 minute break strategy above. Schedule chunks of time to write your notes when you won't feel stressed about other things. Do what works for you to get the work done well. 

And if you feel like a little help with the technical part of writing is what you need to save yourself some time, check out my free Private Practice Paperwork Crash Course. In that course, I share strategies for simplifying your documentation and identifying templates that work best for you... another great time-saver. 

Like the tips in this blog post? This blog is part of the compiled tips in the ebook Workflow Therapy: Time Management and Simple Systems for Counselors. 

Feeling Stuck With a Client? 3 Ways Your Documentation Can Save the Day

We've all been there. That moment in session where you realize you've had this same discussion with your client before and it ended up nowhere. That moment you see a family or couple bringing up exactly what they seemed to have already worked through. That moment you find yourself searching in your mental toolbox but come up empty-handed.

That moment where you have nothing to say and are having difficulty finding hope in the situation yourself.

While these situations are uncomfortable and often disconcerting, they hold huge potential for growth and change. But as with most obstacles that seem like a 12 foot wall, these situations usually require a different strategy in order to overcome.

What's the awesome strategy I have for you in these difficult clinical situations?

Do a review of your client's file.

Before you stop reading, let me explain!

Usually when you come across these clinical scenarios it's after you've done some work with your client. These situations don't typically pop up in week one or two because you're getting to know your clients, they're motivated to change and your plethora of clinical tools are at your disposal. 

But for those times when it's months later and your toolbox hasn't proved as helpful as it normally is, this little trick can be a game changer. 

Because now you are looking at your client with different, more experienced eyes. 

Have you ever had a situation happen where things weren't making sense and then someone offered you some insight... and when you looked back on things you realized all the signs were there early on but you just couldn't see them yet? That's what your documentation can do for you, offer that critical insight.

1. Go back to the very beginning.

Look at your client's intake paperwork. How did they present when they first came in? What did they identify as their main problem? Did they identify goals? 

Also notice if anything seems missing. Perhaps their original paperwork denied substance abuse but you discovered otherwise later on. Perhaps they noted a happy family situation but have talked about nothing but being unhappy in their marriage for the last three months.

Is there anything that pops out at you as unusual or noteworthy now that you know client more? If so, perhaps there is something you can bring up in your next session to change the cycle of repetition or feeling stuck.

2. Evaluate your treatment plan.

Do you have a treatment plan with your client? If not, this is a great time to start one! Talk about their goals, ways in which they feel they have progressed and what they would like to see happen in the future. 

And whether or not you already have a treatment plan, this is a great time to ask about how counseling is going. Do your clients feel things are going well? Does it feel like anything is missing?

If you've already got a treatment plan going, bring that out in session to check in. Are you both on track? Does this plan still make sense? Are there things either of you could be doing differently to help achieve these goals?

Make it a conversation but don't be scared to actually have a treatment plan written out and share it with your clients. This is where the paperwork can be a great catalyst for insight.

3. Review your notes from day one.

Lastly, start with the very first note in your client's file and read through chronologically. What stands out to you? What progress has been made? 

Any topics you find coming up again and again? What were the plans related to those topics? Was there follow through on any homework or plans?

Try to be as open in this process as possible. There may be something that jumps out at you right away that you've never noticed before. There may also be behavior you realize you're enabling or something clinical you realize you've missed and should address.

Really focus on conceptualizing your client's case and how to best meet their needs. This will certainly bring up questions or ideas you can address with them in the next session.

"But Maelisa, I did this and realize my notes are so minimal they don't really give me much information."

That's okay! First, take that as valuable information and adjust your note writing a bit (from now on) to include a tad more detail. Second, ask your client to help you fill in any gaps! Not literally on paper, but start your next session with an overview.

Ask your client about any sessions they found particularly meaningful or any times they felt resistant to things you discussed. Perhaps you can create a "best of" list or a "most helpful" and "least helpful" list. This is a non-threatening way to talk openly about what works and what doesn't and to review treatment overall.

If you're feeling stuck with a client and try this technique out, let us know in the comments below! And if you want more help on using your documentation as a clinical tool, check out my upcoming workshops (inside the Meaningful Documentation Academy) or try using my paperwork packet. Sometimes it takes a little trial and error so be kind to yourself but keep at it. Your clients will thank you. 

What I Learned (about paperwork) from the Road to Success Summit

I had such a great time putting on the Road to Success Summit in June and I learned soooo much from all the experts I interviewed. It was pretty cool to do the interviewing because that means I aaaalllll the content!

I knew the Summit would be helpful for therapists in private practice and my goal was to cover as many different areas as possible. But there was one thing quite obviously missing... a lesson on paperwork!

So, I thought I'd take this opportunity to highlight how your documentation relates to everything in your private practice. And if you're interested in an opportunity join the LIVE version of the Summit, click here to find out more.

Below are the lessons I learned from all the experts who participated, and how it relates to your paperwork:

Casey Truffo and being the CEO of your private practice

-Casey dropped some major knowledge bombs about business in general and has such an easy way of explaining things. The big thing I got related to paperwork was to outline everything you do. Take the time to write out your process so you can later improve, refine and duplicate when needed.

Kelly Higdon and integrating coaching into your practice

-Kelly talked about the differences between coaching and therapy. One of the big differences was the intention behind the service you plan to provide. You might actually be working on the same area (stress at work, for example) but choosing a different way to focus together. And that means, your paperwork will look different! Kelly pointed out that with her coaching clients she actually takes notes during the session and sends them the notes. I do this with my individual consultations as well. We cover a lot so this way the client can stay focused!

Keri Nola and using your intuition in your private practice

-Keri and I talked a lot about the finer nuances of using your intuition in every part of your practice. I think this applies to your paperwork, as well. Don't just include things because you feel you have to, think about how you'd like to write. Never seen something in someone's intake packet but feel led to include it? Then do so! Listen to your heart as well as your ethical guidelines.

Jo Muirhead and creating a successful money mindset

-Money was the topic of Jo's interview and we discussed a lot of the ways we misperceive things and sabotage ourselves by often avoiding the topic. I see a lot of therapists uncomfortable with money and that impacts client care. Because if you're not able to create a clear plan and decide how much you need to charge to sustain your practice, you'll end up reducing your rates out of fear (and often telling yourself it's really out of client need). However, if you have a clear plan that's represented in your policies then that frees you up to provide pro bono or discounted services to those who need it without feeling resentful

Camille McDaniel and adding clinicians to your practice

-Camille brought up some excellent points about hiring and planning ahead. One of things this highlights is being really clear about the conditions of employment ahead of time and also very clearly outlining any conditions of subletting your space. One example she brought up was making sure her subletter's clientele was similar to her own so there weren't potentially awkward situations in the waiting room. 

Rajani Venkatraman Levis and building your practice through community, not competition

-Rajani is one of my favorite people on the planet. That has nothing to do with paperwork but I just want you know how awesome she is. Anyway, Rajani talked about the power of reaching out to others for support, without worrying about whether or not they might be your "competition." It's so crucial to have regular access to some clinicians whose opinions you value so that you can receive feedback when needed. Changing your forms or not sure how to write something up? Call someone you trust so you can talk it through!

Roy Huggins and using technology to serve your clients

-If you know Roy, then you were not surprised that this interview was packed full of extremely useful info! He talked about how the internet actually works and why that means it's our job as a counselor/therapist to review with our clients any risks with technology. Make sure you have a statement in your informed consent about those risks and then document reviewing them with your clients.

Melvin Varghese and starting a podcast 

-Melvin shared some very practical steps for how to start a podcast, as well as the tools he uses for his own successful podcast. He also talked about monetizing his podcast recently and how valuable it has been for creating authority and networking with other professionals. How does this relate to paperwork? Well, do you have a place for clients to write down where they found you? This will help you to gear your marketing efforts toward what is working best. And maybe, that's a podcast!

Ernesto Segismundo and using video to promote your practice

-Okay, I'll be honest, it's difficult to tie this interview into a documentation lesson. But you know what? I think Ernesto really highlighted why video is such a powerful tool. What if you had a video on your website explaining your intake process, rather than just telling people to download forms? The more interactive and personalized you can make things, the more your clients will appreciate that effort. And boy, will it make you stand out as going the extra mile!

Kat Love and creating a beautiful website

-Kat shared insight into how to create a website that is appealing your clients. This is huge because you're competing with all sorts of distractions online. Since my focus is on making your documentation meaningful to both you and your clients, this really begins with your website copy and presence. Make sure everything flows together smoothly. Use a lot of casual language and pretty colors on your website but then have very stoic sounding forms that are all black and white? That's a mismatch! So continue your branding from website to forms to service.

Clay Cockrell and providing counseling online

-Clay provides counseling online and also runs a directory for other therapists who provide online services. Since this whole online counseling thing is so easy for him, he shared sooooo many resources and tips! One big tip? Create a plan for what you'll do when technology fails, because it will at some point. If you're providing counseling online, include this in your informed consent form or create a separate document that explains what you'll both do (for example, will you call the client or should they call you?). This can decrease any stress that may occur, for both you and your clients.

Barbara Griswold and responding to insurance inquiries

-In Barbara's interview we talked about dealing with insurance companies and she shared a lot of the mistakes she sees therapists make. One of the big things is thinking they don't need to worry about insurance ever seeing their paperwork. Although it's not super common for insurance companies to audit your files, it does happen. And the way in which you document can impact whether or not your client's services will be rejected. So, even if you're just providing a super bill, make sure you're well informed about what's needed.

Samara Stone and building a practice based on insurance

-Samara talked about why it's important for her to have a large practice that bills insurance and also shared some of the mistakes she made early on when using insurance. One of the biggest mistakes was being unfamiliar with the billing process. Once she decided to suck it up and learn what was needed she was able to make sure billing was going smoothly. And, that allowed her to know the right person to hire when she needed to outsource that task because of the time it was taking. 

Nicol Stolar-Peterson and creating a court policy

-In Nicol's interview I tried to start off with "what do we do when we get a subpoena?" and Nicol let me know we had to back up first! Why? Because responding to legal requests and whether or not you get paid to do so is all about what you have in your court policy. So make sure you've outlined that ahead of time and don't get caught losing money while waiting around in the courthouse just to assert privilege. 

Agnes Wainman and identifying your ideal client

-Agnes talked about why it's important to identify an ideal client and then actually walked me through some exercises to do that. But marketing isn't where this stops. Make your intake paperwork speak to your clients, as well. Continue that relationship from whatever made them call you to them completing their forms and walking in your door to the two of you working together. If your forms are personalized to their needs, they'll immediately feel a sense of relief for taking the step and reaching out to you. 

Allison Puryear and networking your way to success

-Allison and I talked about how you can choose networking strategies that are specific to your personality and work with your strengths. Wondering what to talk about when you meet with other therapists for networking? Ask them what type of notes template they use! Trust me, most counselors are actually interested to talk about it because they're dying to hear what you do, too!!

Stephanie Adams and creating systems that sustain your practice

-And we're back to where we started... with systems! Stephanie focused on the ways in which creating systems for her practice has saved her time and stress. One of the first systems I recommend you automate and really spell out is your intake system. How do you give clients info in the beginning, how do they sign and read forms, how do they pay you, will you remind them of their first appointment and when, etc. Writing this all out will save you a lot of stress in the long run.

If you didn't get a chance to watch all the interviews, then check out the interviewees who sound the most useful to you. They ALL have great resources to be used at different points in your practice.

Also, make sure you're signed up for my weekly newsletter so you never miss info on awesome stuff like this! I've got a few things planned coming up, including some live workshops across the U.S. You won't want to miss it!

10 Tips for Documenting in Crisis

In the wake of the Orlando shooting, I noticed questions popping up about how to obtain consent and document therapy when providing crisis services. My goal is to support you in the awesome clinical work you provide so I've compiled a list of tips for how to proceed quickly so you can get in there and be a support for others.

Two common ways in which this occurs is that you'll either volunteer services through an agency or organization of some sort, or you'll offer to provide services in your office. Since these situations present different responsibilities on your end, I've separated the tips out. 

If you're providing services through a crisis center/agency/other organization:

  1. Ask. Make sure you check in with whomever is in charge to see what is expected of you. Is there a brief form you should have people fill out? Where should you write a note documenting whom you saw and where does that note go?
  2. Make suggestions. It's very common that systems and procedures are not set up in crisis situations. This is your opportunity to provide a nice suggestion. Offer to use your own note template or informed consent language. Offer to meet with other counselors and determine a protocol. Take a leadership position if necessary, because people are counting on you to be the professional.
  3. Document anyway. In some situations you may be encouraged to be more lax. While I agree this isn't the time to split hairs, crisis situations don't give you a free for all. You're still a professional with ethical guidelines so even if someone in charge wants to give you a pass, write up a note anyway.
  4. Be timely. No matter how chaotic things may be, do any required documentation immediately. It is too easy to get caught up in the whirlwind around you and then forget what happened with the 9th person you saw that day. Be responsible and take the time to get notes done. 
  5. Check in re: follow up. Make sure you have a clear sense of what will happen after you meet with someone. Is this a one-time debrief or an opportunity to connect with more ongoing counseling? If you feel someone needs additional services, where do you recommend they go? Set yourself, and the people you will meet, up for success rather than disappointment or abandonment. 

If you're providing services in your office:

  1. Reduce and reuse. Go through your intake and consent documents and identify what is the bare minimum information you need to review with someone before proceeding. Crisis likely isn't the time to go through your social media or texting policy, but you do still want to establish some boundaries and expectations.
  2. Explain yourself. When you choose to do the minimum necessary, it's important to explain why. Use your progress notes to explain why you chose to leave out certain things. This is your chance to provide your rationale.
  3. Be timely. Do these notes right away. When emotions are high it is very easy to forget specifics, even though you think there's no way you'd be able to forget such details. Even if you're behind on notes for other clients, do these crisis notes NOW.
  4. Be clear about follow up. Clearly identify with the client and clearly outline in your notes what the plan is for follow up. Is this a time-limited or session-limited series you're providing? Are you meeting with someone in the absence of their own therapist and planning to provide a connection at a later time? Or is this potentially a new client for you? Additionally, you'll want to be clear about who the client should contact (and how) should they feel the need outside of your session.
  5. Revisit when it's appropriate. If you end up seeing this client more long-term, it doesn't mean you get a "pass" for reviewing all that stuff you originally omitted in the beginning. After a few sessions, revisit those things (like your cancellation policy, etc.) that may not have seemed so crucial in the crisis moment. No need to ruin a good therapeutic relationship because you both weren't on the same page two months later.

Of course, crises are as wide and varied as the people involved in them, but these tips can help you have some order and direction in what is often a chaotic situation. 

What other tips do you have for documenting in a crisis situation? Share in the comments below and let us know what has worked well for you... or even what didn't work well and you'd never do again!

Writing Less is Writing More: Reducing the length of your notes

Regarding length of notes, I typically hear two things... either "You'd probably wince if you saw how little I write" or "I feel like I write too much."

One thing I recommend for both issues is to use a regular notes template and pair that with the note writing prompts available in my free Private Practice Paperwork Crash Course. But for those who write too much, even that won't necessarily solve the problem.

This is something I've had to work on myself, since I tend to be wordy. I've also had a lot of experience with more unstable clients who required a little more documentation than the "average" therapy session. Side note: when dealing with crisis, make sure to clearly spell out your actions and the rationale for those actions. Include a follow-up plan and then document the actual follow-up. 

This made shortening my notes a little more difficult but as I've worked it through it, I figure I'll help you do the same! Let's take a simple notes template, like DAP (Data, Assessment, Plan), and look at how we could pare down a long note...

Here is a note for our hypothetical client, Maya. We'll look at each section separately to see what things we can take out.

First, let's check out the Data section:

Long Version: Client arrived five minutes late to session. She looked really stressed and was in her workout clothes. I offered her water and had her sit down. Reminded her of the mindfulness exercises we reviewed last week and asked how she did with practicing them over the last week. She talked about difficulty concentrating and about how her son kept interrupting her so he could get help with homework. She asked her mother to help him but she was busy as well. Client spent much of the session making excuses for why she probably won’t be able to implement the exercises at home. She then started talking about wanting to go on a “girls’ retreat” for the weekend with some friends and how it’s the only thing that helps her feel better these days. She was reluctant to leave the session at the end and said, “This is so helpful. Thank you for being here for me. I don’t know what I’d do without this.” Then left immediately.

You may notice a LOT of extraneous information. There are also lots of details that aren't necessary. This is just a matter of sticking to the most important facts and taking out our really specific language. Here is how we can make this note a bit better (and shorter):

Short Version: Client arrived late and appeared flustered. Reported feeling stressed and having difficulty implementing mindfulness based exercises previously reviewed in sessions. I assisted her in practicing the techniques and problem-solving ways to implement at home.

See? The details about difficulty making a decision on whether or not to attend a girls' retreat and exactly how she attempted the mindfulness exercises are irrelevant. We still get a good sense of how she is progressing and what happened during the session without having a total play-by-play.

Now, let's look at the Assessment section:

Long Version: The client seems resistant to implementing practices discussed in session and continues to be stuck in a recurring cycle of promoting her anxiety. She appears to prefer excuses to trying to work on her goals. She continues to use her son as an excuse so she does not have to focus on her own needs or working through her own issues with guilt and anxiety. However, also presents as somewhat codependent, declaring how helpful therapy is even though she doesn’t follow through.

Okay, for this section we have some quality concerns... namely, the very subjective language. How do you think Maya would feel if she read that? Probably not great. I'm not saying our goal with notes is to appease our clients, but we should be respectful and as objective as possible, even during a more interpretive section like the Assessment. 

So how could we word this differently and also make this shorter? Let's see:

Short Version: Client is having difficulty managing her needs with family demands. Remains committed to therapy.

Did that just blow your mind right now? It's so short! But really, considering this session, there's not much more we need. We already discussed her difficulty implementing techniques in the Data section and there's no need to harp on that point. 

Instead, we focus on what all the stuff in the Data section means as far as what we really need to be working on. We also kept things very objective while adding something positive about her treatment thus far. 

Okay, now let's look at the final section, the Plan:

Long Version: Client will try using meditation and journaling again over the next week. She will update me on her progress with mother and son. We’ll meet again on 06/02/16.

This section is pretty easy to keep short, regardless, so I didn't make as much of a change here. But I did take out the extraneous information and simplify things... 

Short Version: Client will practice exercises reviewed in session. Next session is 06/02/16.

And there you have it... a great, simple note! I want to summarize a few pointers based on the differences between these long and short versions:

  • Remove extraneous information that's irrelevant to treatment or progress.
  • Remove the “gory” details and use more general language.
  • Keep the general focus of the session as the focus of the note (without letting other things distract you!).
  • Leave out subjective language and consider how your client would feel reading the note
  • Leave in client quotes if they're relevant. They often say more than any interpretation you could create.

If you liked this breakdown of how to simplify your notes, you may also want to check out my upcoming trainings and my paperwork packet. I not only offer forms (which includes four different note templates) but also spell out directions for how to implement them. 

I love doing this stuff and if it helps you, everybody wins!

What were your takeaways from this post? Any ways you can improve your notes? Write a comment below and let us know!

Like the tips in this blog post? This blog is part of the compiled tips in the ebook Workflow Therapy: Time Management and Simple Systems for Counselors.

Simplifying Your Informed Consent

Informed consent is a whole process, not just a form. And it very easily gets convoluted, long and confusing. But it doesn't have to! 

We can make the process a lot more simple and easier for both ourselves and our clients (I mean, it's really for them so we may as well make it simple, right?!). I've got some tips below to help you cut out the confusion.

Make it a conversation

Informed consent is NOT a form... it's a process and a conversation you have with your clients. So use the key points you want to highlight and think of them as talking points instead. These are ways to introduce your clients to the parameters of the therapeutic relationship.

The paperwork is just a representation of the conversation you have.

Give examples and explanations

Since it's a conversation, make sure you use stories and examples to explain the concepts. For example, confidentiality may be a bit ambiguous to some clients. But if you provide some common scenarios that relate to your client it can become much more clear, opening up the opportunity for clarification before a situation gets awkward.

For example, if you notice that your client's address is very close to your own you may bring up the scenario of how you would respond if the two of you saw one another in public. Or you may discuss with a client who prefers texting the possibility that others may see their appointment reminders on their phone's home screen.

And if you work with children or teens, I definitely recommending having a detailed conversation about what kind of information will or won't be shared with parents and how that might happen.

Use layering

The things you need to include in your informed consent constitute a loooooonnnnnnggggg list. It's not realistic, or even preferable, to review everything in the first session or two. Instead, choose what is important to discuss based on what your client presents.

Yes, there are certain things you should discuss with everyone right away, like confidentiality, how to get a hold of you and how much you charge for a session (and a missed session). But most of the rest you can adjust as needed.

Highlight the main points in your informed consent and clarify any questions. Then use your clinical judgment about the areas in which you may need to go more in depth. 

Your client mentions they'd prefer texting reminders? Go in depth about that topic. Your client says nope, no texting? Then no big deal. Remember, this is a process, not a form. So you will revisit things as they come up... like when that client eventually DOES text you they're running late ;)

Ask your clients about different topics to see what matters most to them. See if they have any questions about your policies. Talk to them about any prior experience in therapy and if they have questions about things you may do differently. These are all great ways to get the conversation going while simultaneously reviewing informed consent. 

If you still want some more details on this topic, check out the webinar I did with Roy Huggins from Person-Centered Tech. You can earn one CE credit for watching and get even more great tips!

And let us know in the comments below... how do you review informed consent?

Like the tips in this blog post? This blog is part of the compiled tips in the ebook Workflow Therapy: Time Management and Simple Systems for Counselors.

What is a Notice of Privacy Practices?

You may have heard about a form called the Notice of Privacy Practices but not really be too sure what it's all about. In this video I'm helping to clear all that up! Click below to watch...

While the Notice of Privacy Practices is a complete form, the main aspects that apply to therapists in private practice include:

  • Your record keeping policies
  • Your client's access to records
  • How you share client information
  • Opportunities for clients to file a complaint

Healthit.gov provides an excellent sample form that is both visually appealing and covers all the necessary bases. Click here to view the sample. 

Remember that even if you're not a HIPAA covered entity, many of these principles are still considered best practice to include in your informed consent process. 

The key, as with everything, is to determine how these principles apply to your clients and use that for discussion. Let us know in the comments how you include these principles in your forms!

A Counselor's Story of Falling Behind in Writing Notes

Let me tell you a story, the story of the typical therapist who comes to me saying they are behind in notes and desperate for help... 

We'll call our imaginary therapist Dorothy. Dorothy has been licensed for about two years and started her own private practice shortly after getting licensed. Before that she had a supervisor who would check in with her about clinical things and periodically about paperwork- just making sure it was done.

But now that Dorothy is the Owner of Oz Counseling she has a lot of other things on her mind besides client care and documentation... she attends networking events regularly with the hopes of growing her connections, makes sure to answer phone calls from potential clients, does her bookkeeping (as regularly as she can), decorates her office, works on her website ("that new picture will hopefully make a difference this time") and does about a hundred other things that take up time!

Ultimately, being a good therapist is what's most important to Dorothy. She's good at it and her practice is slowly growing as a result. But all the demands on her time have impacted one thing pretty significantly. She is getting behind in her notes.

Dorothy would never just NOT write notes so she does what lots of other therapists do but never talk about- she jots down quick notes to herself between or during sessions. 

These are just little notes on a steno pad but they remind her what was talked about in the session. Then she can go back and write the full note when she has time... tomorrow... or this weekend... or next week...

The pattern continues until Dorothy has about six months of notes on her steno pad and none in her client files. Now the task of writing those notes feels very overwhelming. She feels a sense of guilt and regret when continuing to take her quick notes on the steno pad.

But what other option does she have? She's so behind at this point. Better to have something than nothing, right? At least when she's able to finally sit down and write those notes it will go pretty smoothly because she has a backup.

Fast forward another month and Dorothy takes a day off seeing clients to start catching up on her notes. She looks at the stack and a huge sense of dread washes over her. This will take sooooo long! 

But she is brave and dives in anyway... and is devastated to find her brief notes she's been counting on aren't quite as clear six months later. She spends most of the time trying to connect the dots and make sense of what she wrote. After two hours she has barely made a dent in the workload and bursts into tears.

How could this happen? She was so sure she'd been making good notes for herself! Now she is scared. What if Tin Man requests his records next week? It would take days to get his notes ready. And Cowardly Lion is such a volatile client. What if something happens and someone wants to see his record?

She freaks out for a bit but then she goes to the all powerful internet to find some help. She types in "How to catch up on therapy notes" and finds... me!

Yes, I'm able to help her catch up (and that part is really important) but how do we know the pattern won't happen again? What was it that led Dorothy down this road?

Like my reference there? ;)

After working with dozens of therapists who struggle with getting documentation done on time I've discovered that time management with paperwork is largely dependent on the emotional connection the therapist has to the paperwork.

It's interesting to me that almost every therapist I've helped to catch up on months of notes has taken these quick notes religiously. So they are writing notes (not ethically sufficient to be considered in the client record but still notes), but think they're not. 

That leads me to believe this whole note writing thing is largely a mental game. 

Then I hear stories of counselors being berated by supervisors for poor documentation... but not being told what good documentation looks like. And I hear therapists say they never received any training in writing notes. They've just been winging it most of their career and assume it's okay.

Put all that together with the fact that most of us have insecurities around running our practice, feel guilty charging people for our time, and often burn ourselves out caring not only for clients but also for everyone else in our life. 

Yeah... recipe for disaster. 

So how do we fix it? By doing what we would tell our clients to do. We look at the cause of this issue with writing notes... then we create a plan of action and learn tools to make things work.

And we forgive ourselves for prior mistakes. We focus on loving ourselves, healing the relationship and changing our behavior for the better. 

Last year I created a training video to help therapists with this task of catching up on notes. I only offered it to those who were signed up for my email list but now I want to share it with you, because I think this is really important and I know this will help.

But promise me that you'll spend some time (even just 10 minutes) thinking about why you're behind on your notes before going to the action plan. Because if you don't take that time you'll just end up bookmarking the action plan to use every 6-9 months. 

I'd rather you create a whole new relationship with your documentation so that it's not something you're avoiding or dreading. 

Now do something that will truly change your life by taking that time and then let us know in the comments below. What keeps you from getting your notes done?

Then click here to watch the free video (and ignore the registration deadline at the end of the video). 

Like the tips in this blog post? This blog is part of the compiled tips in the ebook Workflow Therapy: Time Management and Simple Systems for Counselors.

How to Start a Consultation Group

We're finishing up this "How To" series with something that can help you for the life of your career, starting a consultation group. 

Now, obviously I'm going to put a documentation spin on things (because that's why you're reading my blog!) but I've also got tips that apply to any clinical consultation group.

Not only am I the Documentation Diva but I'm also a supervisor and trainer. So I've collected some pretty awesome strategies for stretching your clinical muscles over the years. 

Getting the Group Started

There are two main ways to get your group started from scratch. The method you choose will likely depend on the purpose of your group and your particular clinical needs. First, identify what those are by answering these questions:

"What is our main purpose and our long-term vision?"

"Would various levels of experience work well with this group?"

"Are we focused on similar clientele, modalities or are we open to all types of treatment and specialties?"

"How many people would work well in this group and what is the limit?"

Now you have a place to start and can focus on one of the two main options below. But remember, a consultation group doesn't have to be limited geographically. You have many options for doing this group with others across the country (or the world!). Don't limit yourself.

  1. Start with a group of people you trust. Maybe you have a few colleagues that are already in the back of your mind as awesome people you trust and would love to meet with more officially. Easy, just shoot them an email or give them a call with your idea and bam! Consult group started!!
  2. Start with a topic of interest. Perhaps you don't have clear people in mind or are interested in focusing on something specific. In this case, you can reach out to a listserv, Facebook group or LinkedIn group to see who is also interested in your topic. If you go this route you'll want to have clear guidelines set up already so you can gauge who will be a good fit and try things out for a time. 

Now that your group is ready to go, I've got some ideas for what to actually do when you meet.  

Activities for Your Group

Below are 10 different activities for your new (or existing) consultation group. So if you decide to meet once a month you've got almost a year covered!

Identify the purpose of the group and the format. Your first meeting should clearly outline what is expected of everyone. You want to think about things like confidentiality, handling conflict, attendance expectations, method for accepting new members, who will take the lead and for how long, and how often you'll check in to see if the group is still meeting everyone's needs.

Do mock therapy sessions with one another, especially if you're focused on a particular modality or clientele. Remember how terrifying this was in grad school? Because we didn't know what the heck we were doing! It's just as important to do as we become more experienced. And it's a great way to get feedback on your own clinical style as well as pick up some new tips.

Write notes as a group. You can either do a mock therapy session and write notes based on that or someone in the group can describe a situation about which to write notes. I recommend you take 5-10 minutes for everyone to write individually and then (be brave) and share together. It's awesome to see the different styles but I guarantee you'll also be surprised to hear how similar the notes are... you just don't know because you never read anyone else's notes!

Present ethical dilemmas... like, your absolute scariest scenarios (or even the boring ones that happen all the time, like clients texting even when you told them not to). Maybe it's a story you read or heard from a colleague, maybe it's something that actually happened to you. The cool thing about ethical dilemmas is there's no black and white answer. And that's often where we find ourselves, walking in the grey areas. So bring it up and see what your colleagues are thinking!

Have an "intake day" where everyone brings in their intake forms and shares strategies with one another. You can pass the paper forms around and make comments for others while also taking some notes for yourself on ways to improve your own forms.

Train one another. Did someone just attend a really great conference? Maybe they can summarize some of the greater points in a handout or presentation. Have a topic you'd love to learn more about? Put something together and share it with the group.

Identify your clinical week. Have everyone share what their week looks like. You'd be amazed to hear the variety in schedules we all have. Perhaps you'll get an awesome tip from a colleague like Mari Lee, who takes every fifth week off from sessions.

Write a business plan. Many therapists have heard about business plans but feel intimidated actually writing one up. So do it together! Download a sample online and help one another through it. Share ideas and explain your plans to one another to get feedback. (You can read a great article on creating a business plan here)

Practice initial client phone calls. Similar to the mock therapy sessions, pretend to be an interested client and see how everyone does their initial screening calls. 

Watch a webinar or other training together and then discuss how it applies to you. I do monthly webinars and also have tons of trainings available if you're on my email list but you can also check out other things on topics of interest to your specific group.

Now the only thing left to do is to get out there and get started! Make sure you drop back over here to let us know how it's going. 

Looking for a little more structure and need help with your documentation? Check out my Meaningful Documentation Academy! This is the only time we're open for enrollment in 2016.

Money and Paperwork: The Emotional Impact on Counselors

Get a group of counselors together (in person, in a Facebook group, anywhere) and a few topics will inevitably come up... 

How much they dislike marketing and selling (but how they know it's needed for a successful practice)...

Disdain for insurance and difficulty getting paid by insurance companies...

A true desire to help clients and passion for clinical work...

Fear of not being able to do that awesome clinical work and earn a decent living...

I have lots of amazing friends who are therapists and I know plenty of talented colleagues. So how come when we all get together there seems to be a pervasive fear of success and almost innate insecurity about our skills?

Don't get me wrong, that's not the case for all counselors. Many are confident in their skills and abilities as well as business savvy. But I do find that most counselors struggle with confidence. 

We could get into an infinite number of reasons for this and discuss endless related topics. But I'm going to stick with a couple areas that relate to my focus (because I only claim to be the Documentation Diva, not the Everything Diva).

So let's narrow this apprehension down to money and paperwork

This is something I ended up talking about with Matt over on his Virtual LPC podcast. And I notice it comes up with a lot of other counselors on his podcast as well. 

There is this fear that no one will want to pay for our services unless there is some sort of discount. I actually had this come up for myself recently. I immediately went to consider a big discount for a client... before they had waffled in their decision, before they asked about it, and even before I had run the numbers to see if it truly made sense.

Why the heck would I do that?! Because I was scared... afraid that someone wouldn't pay what I asked.

And it was totally irrational. 

I was offering a quality service at a very good price. It was an excellent investment for this customer. They saw the value in it right away and there was really no reason for this fear. 

Now imagine having this sort of fear or apprehension every time a potential client calls. That would be exhausting! And really unnecessary. 

But how do we overcome this? Well, as usual, I've got some tips for you...

  1. Talk about it. The best way to overcome fear is to face it head on. Talk with your friends and with colleagues. Talk with your own therapist. Figure out where any insecurity or fear may be originating and work through it.
  2. Surround yourself with successful people. Notice I used a general word here- people (not counselors or therapists). Make sure you connect with successful business owners. Soak up their strategies, their mindset. Be open to lessons you can learn from business owners both inside and outside the field of mental health.
  3. Surround yourself with generous people. Most of us got in to mental health because we genuinely enjoy helping others. However, this doesn't have to be mutually exclusive to financial success. Spend time with people who are successful and generous. It will not only help your mindset but will also give your more resources to help others.
  4. Read up on money mindset. There are tons of great books that offer inspiration on changing your money mindset. If you tend to have negative feelings around money (whether that's fear, resentment, desperation or lack) then make a small investment in a book or two and potentially see some significant change in your life. I mention one of my favorites on Matt's podcast :)
  5. Create a business plan. This is really freaking practical and necessary. There's no use worrying about money when you don't even have a clear idea of how much you need for personal and business expenses. Lay out everything- retirement, vacations, sick time, groceries, rent, etc. This sounds really intimidating to a lot of people and is something many of us avoid. However, this one thing will help you clear a lot of anxiety and get very focused on where and how you focus your philanthropy. 
  6. Incorporate a sliding scale or pro bono policy. I always recommend therapists have a clear policy surrounding sliding scale or pro bono clients. Some things to consider are... Do you require proof of income? What percent will you slide for each income bracket? What circumstances warrant a pro bono client? How many sliding scale/pro bono clients can you afford? Will you re-evaluate need at certain intervals (I recommend every 3-6 months)?

To make this whole process simplified I have a free cheat sheet for you. Click here to download my Sliding Scale Worksheet. This is a worksheet I give members of my Meaningful Documentation program so they can figure out exactly what type of fee feels right and fair for both themselves and their clients. 

Hopefully these tips and the worksheet will help ease any anxiety you may have around money and paperwork. But remember that this is an ongoing thing... it's not something you think about and address and never worry about again (which is why #1-3 are so important). 

What other tips do you have or what strategies do you find useful when fear or anxiety arise? Leave a comment below and share. Let's all be a support for one another... that's the biggest key to overcoming this in the long-term.

3 Ways to Make Your Consent Form Less Boring

Did you know reviewing your consent form with your clients is your first opportunity to start a meaningful conversation about therapy? Seriously, it's way more than just a form. So don't think your first session has to be this super impersonal time reviewing paperwork. 

Let's jump straight into the three ways you can turn your form into a meaningful conversation...

1. Personalize it.

Many therapists think their consent form has to be super formal since it's a legal document. But who says?! Bring your personality to the table right away. If you and your clients are more formal, keep it that way; but if you tend to be more relaxed or playful then add that to your language.

Use language such as "you" and "we" instead of "client" whenever you can. Break up the form so it's not a long box of text. Think through what therapy looks like with you and include as many of those pieces as possible.

Another way to personalize your consent form is to add cultural pieces to it. Make sure the form is relevant to your specific population. Work with kids? Address things like what will happen if a parent asks details about a session. Work with couples? Address what confidentiality will look like if one person asks for records later on. 

It's simply a conversation about how therapy looks, as realistically as you can offer.

2. Create the framework for the relationship. 

This is your chance to put into words the role you play as the counselor. What's expected of you? What's not expected of you? What limitations do you have in your role? What are common misconceptions you encounter that it's important to address?

It's also your opportunity to share what is the client's role. We all know this is a key component of the "success" of the therapeutic relationship... the client's motivation and expectations. However, very few therapists actually discuss with clients what they expect of them.

This means concrete things like arriving to sessions on time and paying for missed sessions without prior cancellation but it also means a lot more. Do you tend to assign homework? Do you expect clients to follow through with things in between sessions? Do you expect clients to talk or participate in other ways? 

These are all key elements to ensuring your clients are aware of the coming journey with you. 

3. Use the form to initiate questions from your clients.

This is the time when you want clients to ask questions about therapy. You want to know what their concerns are. Have they had any previous experiences with counseling and was it positive or negative? What do they expect to happen?

All of these things turn a conversation about a form into what it was originally intended to be- a conversation about the relationship. I like to say that your consent form is simply proof you actually talked with your clients about the limitations and benefits of therapy. 

I hope this helps you to change your thinking a little about what an informed consent form can be. My goal is always to help you create more meaning in your documentation... which coincidentally also makes it easier and more simple. 

If you'd like to learn even more about ways to make you consent form that much better, sign up for my free October training series**. This week is all about informed consent and I've got even more tips for those who sign up. 

Happy writing!

**This training is no longer running, but you can always sign up for my FREE Private Practice Paperwork Crash Course, or check out my Meaningful Documentation Academy for tips, trainings, and more!

3 Ways to Use Facebook Groups to Improve Your Documentation

News flash: Facebook groups are NOT consultation groups! However, they can be useful when used the right way. In this video I've got some tips on how you can ethically use the hundreds of therapists virtually available for feedback in your Facebook groups. Click below to check it out...

Not getting the QA Prep newsletter yet? Sign up today so you get my free video trainings each month, notices about helpful resources and also the free Private Practice Paperwork Crash Course! See you in your inbox.

The Fear and Loathing of Documentation

Let's be honest, part of the reason this site even exists is because many counselors have two main feelings related to documentation: fear and loathing. I hope things like the blog and my Crash Course help to lessen some of that but I know it's an ongoing struggle.

But why? I mean, we're talking about people with Master's Degrees and Doctorates here! What in the world is so scary about a little bit of paperwork for someone who wrote a thesis or dissertation? 

Many therapists talk about documentation like it's this huge task because they truly feel that way. But they often don't take the time to examine why, and even fewer take the time to do anything about it. 

I'm a firm believer in identifying fears as the first step to moving through them. So let's take an honest look at the fears around psychotherapy notes... and some strategies for overcoming these fears.

1. Fear you're not writing your notes the "right way"

This is what I hear from most therapists I talk with. They're in private practice and no one ever looks at their notes. They had minimal training during internship or they were trained in a very specific format geared toward an agency. 

The truth is, there's no "right way" to write notes for private practice! As with many things in life, there are guidelines to follow but not specific rules. And I personally think that's a good thing!

You have the freedom to personalize your notes to your clients, to a specific population or your methodology. I recommend creating a structure for yourself by trying out a few different templates and then sticking with what works for you. Don't limit yourself but don't overthink it. 

Check out how one therapist did this for her EMDR practice by clicking here.

2. Fear you're not doing good work

Ouch, yes, this a truth bomb. But some counselors are simply scared of other professionals seeing the clinical work they're doing. The fear goes beyond just writing notes "the right way" and in to wondering if they're even providing good clinical care.

In this case, the best solution is getting good clinical consultation. I'm not talking about posting a question to a Facebook group and weeding through 37 responses by clinicians you've never met. I'm talking about a real phone (or live) conversation with a colleague who specializes in the area in which you have questions.

Ask your previous supervisors, classmates or suitemates for consultation or a referral for someone they know. Do some research online. Whatever you do, build a good network of 3-5 colleagues you can call when you have a question, get stuck or just need some encouragement.

Remember, in any questionable case you'll be judged by whether or not you acted ethically based on what your peers perceive. Keeping a pulse on that is crucial. It also serves to continually challenge you as a clinician.

3. Fear your notes will hurt your client

Speaking of ethical situations, another common concern I hear from therapists is that if their notes are ever presented in court those notes will inevitably hurt, rather than help, their client. 

First of all, there's some validity to this fear... because it has happened. And I can't guarantee you it will never happen to you. But I can show you how to craft your notes so they serve a (meaningful) purpose and minimize risk in all areas. 

The key is to make sure your notes tell a story. I like to think of notes as the story of your client's journey in treatment... the abridged version. They don't have to go through every gory detail but they do need to let the reader see a glimpse into the room. 

It's a delicate balance of writing enough to show you acted ethically and can jog your memory years down the line if needed while also avoiding a transcript of words that could potentially be twisted later on. 

If you're struggling with how to do this, I encourage you to consider signing up for a consultation with me. We can go through your notes together, without judgement and without fear of any retribution. 

I strongly believe that most therapists can overcome their documentation fears and make writing notes a meaningful practice. This is my mission with QA Prep- to take something that is meant to be valuable (but often ends up being a chore) and infuse some life into it. 

Do you relate to any of these fears? Feel free to share you thoughts in the comment section below. 

When You Need to Think Like an Agency

Most counselors in private practice are accidental small business owners. They love the idea of having a private practice- the flexibility with scheduling, choosing their own clients, and the ability to have their own private office space.

However, they typically don't enjoy many of the business-related tasks with owning a private practice. They rarely think of their practice as a business but rather see themselves as a simple service professional. 

Regardless of the size of your practice, there are times to think like a business, and more specifically, to think like an agency. That's right- sometimes you actually need to think like an agency in order to protect your practice and also improve the work you provide your clients. 

You may be thinking "but I left an agency so I could actually do what I think is better work for my clients!" This is often true and the two ideas are not mutually exclusive. Let me explain...

Agencies have a lot of liability due to the fact that they employ people who are often dealing with complex clinical issues and safety risks. For that reason, they need to create policies and procedures, train employees on these P & P's, and regularly evaluate the effectiveness of the work they're doing. 

Now let's be honest. Some agencies do a really poor job of this. I'm not disputing that fact. However, the principles are excellent. They create a safety net when working in high risk situations and seek to provide guidance for dilemmas before they arise. 

Maybe you're sold on the idea but the thought of implementing sounds like a monumental task. Not so! Here are four things you can do to improve your psychotherapy practice that you can implement in an hour or less:

  1. Write out your sliding scale policy. This is an area that presents a lot of resentment and confusion for counselors in private practice. Many therapists decide on a sliding scale on a whim and few ever outline criteria for determining their scale or a timeline for reevaluating the client's need. Consider the clients who are currently on a sliding scale. Consider your ideal client population. How many sliding scale slots can you reasonably maintain and at what rate? Will you require proof of income/need? For how long will you provide the sliding rate? Answer these questions and bam! You've got a policy. 
  2. Write our your consultation procedure. Ethical dilemmas arise (and usually at the worst possible time). Client needs change and become more complex. In these circumstances it's important to remember you are not an island. There are many other professionals with whom you can consult. Documenting these consultations is important (read more about that here) so write out how you'll do that. Will your consultations be over the phone? Do you have criteria you feel is important to meet before you consult? Do you have certain people with whom you frequently consult? Are you part of an ongoing group for support on clinical issues? Answer these questions and bam! You've got another policy!
  3. Do a review of your client records. I frequently recommend this because it is so valuable. Choose 1-2 records and read through them in entirety. Do you get a good sense of the treatment you're providing? Do you get a good sense of the client's needs? The client's progress? Are there clinically significant things you notice you may be overlooking? This is a great exercise to do when you feel stuck with a client and this is something agencies do on a regular basis to ensure staff are providing good care... as well as keeping up with notes on a regular basis! Which leads me to the last recommendation... 
  4. Decide on a reasonable expectation for getting notes done. In private practice you are your own boss. For some people, that's not always a great thing. I find that one area many counselors behind in is writing notes. It's so easy to decide to just go home and make dinner instead of staying to finish notes. Then you enjoy some family time and go to bed (because you need your rest to write good notes). Then the next day something important comes up and then it's the weekend and your kids have activities planned, and so on and so on. One way to avoid becoming backed up is to create what your business would see as a reasonable expectation for getting notes done (hint: this should be within at least one week of providing the service). Write it down as a policy and stick to it like you're an employee. The key here is that you have the flexibility to make the policy work for you. So consider how that works for you individually and stick to it.

There you have it! Each of those tasks will take less than hour but will greatly improve your business status. They'll also help you to avoid a lot of anxiety-provoking situations and create stability for your practice. 

If you feel like this is still a bit overwhelming, consider booking an individual consultation with me. We can walk through the whole process together and get your documentation handled in no time! 

Leave a comment below if you've tried any of these techniques. What impact did it have on your practice? What lessons did you learn about yourself as a business owner?

Professional Wills and Planning for an Absence: Interview with Lawyer and Psychologist Dr. Steven Frankel

It's not every day you get to talk with someone who has experience going into a therapist's practice and reviewing every aspect to make sure it's legally and ethically prepared for any and everything that might happen. That's why I was so excited to meet Mark Roseman and Dr. Steven Frankel of Practice-Legacy Programs. They focus on helping therapists prepare for transitioning or closing their practice... and everything that needs to happen in between. What an awesome resource! 

Thankfully, they're not only a great resource but also two very friendly and generous guys. I reached out to see if they'd let me pick their brains about common things they see and they were happy to answer all my questions... and even give a free presentation download sharing more about setting up a professional will.

So, check out my questions and the answers from Dr. Frankel below... and prepare to take some notes!

Q: What common issues do you see overlooked when you work with therapists?

A: The ethical and legal requirements terminating a mental health practice, and, especially, the awareness that a successful practice is characterized by ethical planning for practice transitions due to death, disability or retirement.

The study of resilience factors Resilience is important for clinicians to understand and to know how to assess.  It is not typically taught in graduate training because of the mistaken beliefs that it is uncommon (and therefore not worth spending academic time pursuing), and that it is about psychological health rather than psychopathology. (Book recommendation, "Resilience and Ordinary Magic."  Ann S. Masten)

How much to write in clinical records:  We all are well-informed about the categories that must be covered in records, but there is little training about how to decide whether to write more vs. less.  This issue is especially important in clinical (write less, I say) vs. forensic (write more, I say) records.

Practice Models:  e.g., A group practice, the ethical and legal implications of being in a “formal” group vs. a group of colleagues who share office space, secretarial time, office machines, etc., but are not a “formal” group.  There are considerable ethico-legal issues that arise around these issues.

The differences between being a consultant and being a supervisor. They don't teach us the difference between being a "consultant" and being a "supervisor."  Under CA law, supervisors are liable for what their supervisees do, but consultants are not.  Big issue!

Q: What is a professional will and do I need one as a therapist?

Basically, his answer was yes, you totally need one! Have no clue what it is or how to proceed? No problem. It's a larger topic than can be adequately addressed in a blog so Dr. Frankel provided this free presentation that you can download and share with your colleagues (yup, total permission to share away!).

Presentation download not good enough for you? Well, he also provided this video of him actually presenting all the material! You can hear questions from the audience and everything. It's two hours so bookmark this page if you don't have time now. And make the time to sit down with some coffee or tea and watch it this week!

Q: What are the steps to develop a back-up plan so another therapist has access to everything s/he needs if I am out for an emergency?

A: You would need your clients/patients to sign releases to allow another therapist to access charts.  Your informed consent can include an emergency clause addressing this issue.  The clause should be initialed by the client/patient.

Q: What things should a therapist consider when planning for an extended absence, like surgery or maternity leave?

A: Understanding the issue of patient/client "loyalty" in terms of potential client shift to temporary clinician, as an issue.  The covering therapist must be competent to provide the same care you provide. Also, include language about temporary coverage clinicians in your informed consent (see last question).

Q: What recommendations do you have for a therapist who wants to sell off pieces of their practices?

A: Contact an expert organization, like Practice-Legacy Programs, as the issues that are raised are complicated.  They involve practice valuation (which determines the value of the practice), practice brokerage (which brings potential buyers to the table) and transition models, such as: Does the seller retire? …Continue to consult to the buyer? ….Continue to practice as an employee of the buyer, etc?  (And lots more questions you and I have probably never thought of!) 

Good stuff, right? I can't believe all the helpful tools Dr. Frankel was willing to provide along with all the food for thought. 

WARNING: Don't be overwhelmed by it all! It's so easy to feel paralyzed after reading an article like this and thinking about all the aspects you need to consider in private practice. And that's not the intention at all.

Yes, there IS a lot to consider but there's also a TON of resources available to you. So, if you need help making sure your clients are in the right hands after your practice closes (either expectedly or UNexpectedly) then head on over to Practice-Legacy Programs website and learn more.

If you're worried about other things, like marketing your practice or contracting with insurance, then head on over to the QA Prep Resources page and see what other awesome therapists are out there to support you. And post your questions or additional resources in the comments below. 

Making Documentation Meaningful

There are a lot of emotions around documentation for therapists, most of them negative. Fear. Resentment. Overwhelm. Anxiety. Anger. I hear all of these and many more mentioned in networking meetings and Facebook groups. And it's commonplace; like we're just supposed to accept this is how it is and trudge through it for our entire career.

But what if paperwork didn't have to be that way? 

It's now been a year since I started blogging about documentation and I've been getting awesome feedback from therapists around the world. My favorite thing to hear is that I've made someone's work easier by helping them to connect with paperwork. That's right, it really is possible to have positive emotions around paperwork! 

Confidence. Satisfaction. Connection. Peace. Joy. 

So, how is it that some therapists have gone from overwhelm to peace? From anxiety to confidence? I've found that evaluating your mindset and looking at documentation differently can actually make it more meaningful. And that is the operative word for therapists...

Meaningful.

One of my taglines is "Learn to love your paperwork." People often ask me if this is really possible or laugh at the perceived absurdity. I had one person ask me, "Do you REALLY love paperwork?" The honest answer is, it depends. 

Do I love paperwork for the sake of paperwork? Do I love checking off boxes, crossing t's and dotting i's? Do I love poring through mounds of legal documents that are difficult to understand and relate to what I do? Absolutely not!

However, I do love reading the story of someone making a breakthrough. I love writing quotes from clients who have just made an impactful insight. I love writing a report or letter that someone needs in order to access a life-changing service. I also love the feeling of finishing a document I am confident will support me in case questions come up later. 

But how do you go from that place of resenting paperwork and across the bridge to "loving" paperwork? I've found that bridge is Reflection. Taking even 2-5 minutes before writing a clinical note can make all the difference. That time to really focus on the meaning of your session and the clinical outcome gives the paperwork associated with it the value it deserves.

And let's take that even further... what if we viewed our informed consent document not as a required form that needs everyone's signature but as a way to empower our clients and introduce them to parameters of the therapeutic relationship? Because that's the meaning behind an informed consent form. 

Unfortunately, though, many of us have turned these documents into legally required paperwork that we resent and then overlook... and that leads our clients to overlook these things as well. But we have the paper to change that simply with our intention. You can use a Contract for Services or Informed Consent to discuss with your clients the importance and uniqueness of the relationship you'll build over time. 

Doesn't that sound awesome? Imagine if throughout your day documentation was just a reflection of the clinical work you're doing, rather than something disconnected from it! It is possible, it just takes intention. I challenge you to be mindful of this for the next week and be open to the possibility that paperwork can have new meaning. 

And if you're looking for more ways to implement meaning into your documentation, sign up for my free crash course. In it I provide a training on what I call Meaningful Templates, a way to implement these practices more directly into your note writing. 

Now decide on one way you can focus on making paperwork more meaningful in your work. Share below and get support from your colleagues... and happy writing! 

What to Write When You Break Confidentiality

Most of us have been there... that uncomfortable moment when your client is talking about something you know you'll need to report. Even if you've had the unfortunate experience of doing this multiple times, it still causes an unsettling feeling of uncertainty.

Part of that uncertainty comes after the situation is reported and over... when you sit down to write your notes. How much do you write? What do you need to include? What do you want to avoid writing? Will this note cover your butt?

There are a few things you always want to include in your note for that session and a few things you don't want to put in your note. The key here is that you want to provide your rationale for why you broke confidentiality but you don't want to include all the details of the incident itself. 

Include the following:

  • The general reason you needed to break confidentiality (example: client reported an incident of child abuse)
  • Limited details to support this claim (example: client reported her husband beat their son after performing poorly in a sporting event and her son has multiple visible bruises)
  • Your method of reporting the incident (phone call to protective services, online reporting system, etc.)
  • The name of the person you talked with while making the report
  • Any confirmation/reporting number you receive as a result
  • Appropriate plan for follow-up as needed
  • Whether or not you consulted with any colleagues regarding the report and their recommendations

Avoid the following:

  • Further details of the incident- this information should be kept confidential so leave the details to your required reporting form
  • Copies of any reporting forms- keep these in a file separate from your client's personal files

Following these principles should make you feel confident that if anyone reviewed your records they would understand why you needed to break confidentiality to report the incident. They would know that you acted ethically and clearly understand your responsibility. However, they wouldn't be able to recreate an entire play by play of the incident.

As is always the case with confidentiality, provide only the information necessary. Crises and mandated reporting do not give you a free pass to share any and all information. Stick with what is necessary and when in doubt, consult with a trusted colleague. You can even review your note with a colleague to see if they are able to clearly identify why you needed to break confidentiality. Then, engage in an act of self-care! These situations are stressful and take a toll if you don't care for yourself and get the support you need. 

If you'd like more tips on writing notes and keeping your license safe, sign up for my monthly newsletter (and get access to my free Paperwork Crash Course). I send out extra tips and resources and then you'll never miss another helpful blog post! Happy (and ethical) writing to you!!