How to Review Notes by Other Therapists

If you're a supervisor then you know it can feel like a daunting task to sit down and review notes for other therapists. 

Or maybe you've tried to do this for your own notes and found that you're not sure where to start, what to look for, or how to use the feedback you obtain.

Well, this quick video will help alleviate that confusion! 

I'm going to share with you how to structure your review and provide some tips so that you can make it a meaningful experience for yourself and your supervisee. 

And if you're looking for a simple tool you can use to make sure notes have all their necessary components, click below to sign up for my weekly emails and you'll also receive a Notes Checklist.

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Productivity Hack for Writing Case Notes

I've got a quick tip for you that can dramatically improve your productivity when writing case notes and catching up on paperwork!

In this video I share with you the Pomodoro Technique, a popular time management strategy for getting tasks done.

The key to the Pomodoro Technique is taking breaks! Do NOT skip this part and when you're trying it out make sure you stick to the schedule. 

This is one of the strategies we use for the weekly Get Notes Done Hour in the Meaningful Documentation Academy, as well as our quarterly Get Notes Done Days... and people are really liking it!

Let me know how this strategy works for you in the comments below.

Step-by-Step Intake Progress Note

Did you know that your very first progress note should look different from your other client case notes? 

That's because the first session with clients, the intake assessment, is very different from our "typical" sessions... whatever "typical" looks like to you ;) 

In that first session with mental health clients we have forms to review and information to gather. And there are very important things to discuss with our clients so they understand the counseling process.

I recommend including that you reviewed all of these things in every intake progress note you complete (obviously, with the understand that you actually did review those things with the client in session):

  • Limits to confidentiality
  • Potential benefits and drawbacks to treatment
  • Consent for treatment
  • Attendance policy
  • Communication outside of session
  • Reason for seeking treatment
  • Assessment of symptoms
  • Assessment of biopsychosocial data
  • Plan for treatment

Some sections may have more or less detail, depending on the client's situation or length of the session.

For example, it often takes more time to do an intake for child and adolescent clients because we want to get information from the caretakers, as well as the client. Others simply do a more in-depth assessment and take 2-4 sessions. 

When that happens, simply document the portions you did cover (and with whom you discussed it) and then what you plan to cover in the next session. However, I do recommend that you review limits to confidentiality and obtain consent at the first session, whenever possible.

Want to see an example note?

I've got one for you! Check out this sample note below to see how it looks when we put it all together. I'm using the DAP note format here...

Data: 

Client arrived early and had completed intake paperwork online using client portal. Reviewed with client the limits to confidentiality, potential benefits and drawbacks of treatment, communication outside of session and attendance policies. Obtained consent for treatment. Discussed biopsychosocial history further and completed all intake paperwork. Assessed reason for treatment, current struggles and symptoms. Identified goals for treatment. Current goals include 1) Creating a routine for relaxation and self-care and 2) Identifying priorities and planning for work and home tasks accordingly. Client requested weekly assignments to stay on task so we will use this format to start and evaluate after 6-8 weeks. 

Assessment:

Client was comfortable disclosing details about prior treatment and mental health history. Exhibits excellent insight and desire for continued personal growth but is frustrated with ongoing struggles and feels she is not meeting her potential. Previously treated for both depression and anxiety, for which she has created excellent coping strategies and continues to use cognitive-behavioral techniques to address. Currently struggling with symptoms related to ADHD as primary concern.

Plan: 

Client will attend weekly sessions in the office, with the option to move to online sessions if needed. Therapist will assist client in identifying the appropriate weekly “homework” tasks before the end of each session. Client will provide one check-in via journaling in client portal once per week outside of sessions. Weekly assignment is to gather all to do lists and pending tasks to bring in for next session and label with priority level. Next session scheduled for 05/19/17 at 12pm.

You're probably thinking, "Does my note need to be that detailed?"

Maybe not... that all depends on the situation, as well as how in-depth your intake assessment is. For example, if you don't use homework or if you didn't have time to review treatment goals, this note would be a lot shorter.

On the flip side, if you had to do an assessment of safety because the client reported feeling suicidal, your note might actually be longer

Notice that this note doesn't include anything I would have in my intake assessment form.

That's because I see no reason to write the same thing multiple times!

This used to drive me crazy when I worked in an agency. And it's a reason that soooo many therapists resent paperwork and fall behind. That's why I recommend you streamline your documentation as much as possible. 

If you have questions about substance abuse, past treatment, relationships, and suicidal ideation then why do you need to write these things over again in your intake note? My opinion is that you don't need to duplicate this... but you do need to have it documented somewhere that makes sense.

So, if you miss something on your intake assessment form then write it in your intake progress note and vice versa. 

I've got a checklist you can download to create your own intake note template or to use as a reminder when writing your intake notes.

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Should I Use a Treatment Planner for My Notes?

I see a LOT of questions in Facebook groups about using treatment planners for writing therapy notes...

  • Which treatment planner is the most helpful?
  • Will a treatment planner make writing notes faster?
  • How can I use a treatment planner with my electronic health record (EHR)?
  • Will using a treatment planner help me avoid an insurance audit?

But I notice that people are asking a lot of questions without explaining what they really want to know. After fours years of answering questions about writing notes in private practice, I know what these counselors are really thinking. 

And what most therapists really want to know is this:

What tool can I use to make writing notes something I will no longer dread, be confused about, or spend hours of my time doing (or avoiding)?

The answer to that question is not something most therapists are happy to hear. Because there isn't just one tool or strategy that will solve that problem.

However, don't lose hope!

That doesn't mean you can't solve the problem. It just takes a little more effort up front and takes the time of setting up individualized systems that work best for you

When Treatment Planners are Helpful

Treatment and notes planners can be really useful when you have the right mindset about how to use them. Here are some ways they are most helpful:

  • When you're looking for ideas on what to write (for example, when you are experiencing writer's block or starting out with a new method/client)
  • If you need help checking your interventions and treatment plans against insurance requirements, since insurance does want you to clearly connect the treatment to the diagnosis
  • When you're just starting out as a new clinician and don't have much experience to reference
  • If you work in an agency setting where you see a variety of clients and may need to work with multiple diagnoses with which you are not immediately familiar

When Treatment Planners are NOT Helpful

There are also plenty of times that treatment and notes planners are not helpful, despite clinicians trying to use them for this exact purpose. Beware using treatment planners for help with notes in the following circumstances:

  • If you don't treat based on a diagnosis, since most treatment planners are diagnosis-based in their recommendations and ideas
  • If you are looking for interventions and strategies with specific clients, browsing a large treatment planner actually tends to become more overwhelming than helpful (it's counterintuitive, I know!)
  • When you're feeling stuck with a client, because usually you need to discuss this with the client or seek consultation and looking through a treatment planner will rarely give you the insight needed in these situations (here's what I often recommend instead)

Additionally, I find that when treatment planners are helpful it's because the clinician works primarily with one diagnosis and ends up using only the portion of the treatment related to that diagnosis. 

My Top Recommendations

You know I would never leave you without some practical things you can implement right away! So here are my recommendations for how to create your own supplement that can make writing notes more simplified and efficient:

1) Use what you already have.

Rather than buying a book with thousands of options you need to sift through, why not go through your own notes? This is the absolute best way to create a list of interventions and goals that are personalized to you and your clients. 

I go into this process more in depth in this blog post, but in a nutshell all you have to do is spend about an hour reviewing 2-3 client records. Write down the interventions you see most often, the ones that stick out as unique to how you work, and anything else that seems important to you.

Voila! You now have a cheat sheet you can use to create a checklist in your notes template and to help help with writing treatment plans.

Repeat this process for goals/objectives and you'll have another cheat sheet for creating treatment plans (you might have to review more files for this since we use the same goals for many months with the same client). Between those two cheat sheets you'll be able to create very customized treatment plans very efficiently!

2) Have prompts ready. 

One of the easiest things you can do right away is have some note writing prompts next to your computer (or wherever it is that you typically write notes). These questions will help get you in the right mindset to write notes and will help you focus on the things that really matter.

I have a list of note writing prompts available inside my free Private Practice Paperwork Crash Course so that all you have to do is sign up, log in and download your prompts!

3) Set a timer.

Have you ever heard of Parkinson's Law? This states that "work expands so as to fill the time available for its completion."

That means if you give yourself 20 minutes to write a note, it will likely take 20 minutes. And if you give yourself 10 minutes to write that same note, it will likely take 10 minutes! 

This can be anxiety-provoking at first but remember that if you do forget something major, you can always go back and add an addendum to your notes. So it's not the end of the world if you feel like the note is unfinished when the timer goes off.

Over time you'll get better at writing notes more quickly and will feel confident that you know exactly how much time is needed to complete your client paperwork.

4) Get support from colleagues.

I'll bet you didn't know that one of the best ways to feel better about writing notes is to have a colleague read them! Yup, it sounds scary at first but I've found that most therapists are actually doing a pretty good job with their notes. They've just never had someone to tell them this.

Inside the Meaningful Documentation Academy I encourage members to submit notes to me for review. I'll actually read their client note and give them direct feedback. 

But you can even do this yourself. Meet with a trusted colleague and review one another's notes as a quality review. Remove whatever identifying information you can and then spend some time sharing with one another what you liked about the other's notes and what pieces were missing.

Now take some action!

Share in the comments what you plan to do next so your notes can become more efficient, simplified and meaningful to the work you do with clients.

Therapy Notes: Your FAQ's Answered

therapy notes faq.jpg

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!

How My ADD Helped Me With Paperwork

Believe it or not, I was recently diagnosed with ADD. The reasons I was never diagnosed before now are clear. I've always received very good grades, was a genuinely good kid who never caused any trouble, am generally a responsible adult and... I've always been great with paperwork at any job I held.

While receiving the diagnosis was a huge relief for me to explain reasons I've had difficulty with many other areas of life, I began to question how I've been so successful with documentation. Yes, ADD looks very different in each person, but paperwork is supposed to be an almost universal problem for people with this diagnosis! How come it was never a problem for me?

After reflecting on this for quite some time I realized that many aspects of my ADD actually worked to my benefit in completing therapy notes. For real. Let me explain.

Below are some common problems associated with ADD/ADHD that I found I have been using to my benefit this whole time:

Procrastination

Now, this may seem really counterintuitive, but the fact that I regularly (meaning, ALWAYS) procrastinate pushed me to create very firm deadlines for myself when completing paperwork. I know that I can put something off for a really long time. And in my early years as a therapist, I actually had very little supervision regarding documentation, so it was up to me to create deadlines or become extremely backed up. 

While it wasn't easy, I focused on discipline and made sure that I scheduled in time for writing notes and completing assessments. I knew if I didn't schedule it, something else would inevitably take up that time and then, as described in the next reason, I would not be able to produce a quality note. 

Poor Memory

To put it bluntly, I have a horrible memory. So poor, in fact, that if I didn't write my notes within 24-48 hours, I would never be able to write them at all. The sooner, the better for me... and everyone else!

However, I do NOT write notes in between sessions. That just never worked for me. I need the break in between because I've just spent a good amount of energy keeping focus on my client and I need to recharge before the next one.

I either write notes in the session or the following morning, before starting the rest of my clinical day. That way I am able to feel ready for the day ahead and close out what was pending from before... and know it's accurate.

Hyperfocus

Here's where I truly used some ADD traits to my advantage. As many others with ADD/ADHD, I am able to hyperfocus for very long periods of time on things that are of interest to me. So, if I don't write notes in session, I write them in large chunks. That means I rarely sit down to write notes for 10-15 minutes. It's usually more like 45-60 minutes of getting everything done at once.

This means I don't have to pull attention away and I can get in the zone for writing. And because I know that distraction is around every corner, I'll often close my door and shut off things like email during these times.

I create an environment that encourages me to hyperfocus on the task and get it done.

Enjoyment

Some of you may be thinking, sure you can hyperfocus if you like something, but what if you don't like a task... like writing notes?! Well, the key is to find something about it you do like. If you've taken my free Crash Course, you know I talk about creating meaning in your notes and preparing yourself for writing notes.

I literally choose to enjoy the task. First, I know it's a really important thing to do and that helps to motivate me in the beginning. Secondly, I look at writing notes as an opportunity for me to reflect on the clinical work. I view it as a time for me to sit back and see things from my client's point of view or to make sure I'm staying on track with our overall goals. 

It's never a time to just sit down and write notes that mean nothing. This is the time for me focus on my client's session one last time and make sure I've closed any open doors. 

Tips for Dealing with Paperwork for Counselors with ADD/ADHD

Maybe some of the things I've described above help you to see things a little differently or give you some helpful tips to try. But there are plenty more ways to deal with paperwork if you're a therapist with ADD/ADHD. You can also try some of these strategies below:

  • Choose a time that works for you. Make sure the time you're writing notes works to your strengths. For example, I focus better in the morning so that's when I'll write notes... or blog posts ;) 
  • Get accountability. It's scary to admit to another professional that you've gotten behind in paperwork. However, all of us therapists know that talking about something when we feel fear and shame is the best way to overcome those feelings. Even if it's simply shooting me an email, tell someone about the help you need.
  • Incorporate exercise or movement. If you tend to have difficulty sitting still for long periods of time, don't! Write a note, then do 10 push ups or squats. Write another, repeat. I've done this when reviewing paperwork for other people because it keeps me engaged and helps me focus.
  • Try collaborative documentation. If writing notes is a significant point of stress for you, write as much as possible in session with clients. This accomplishes a few things... it will actually help you to be more engaged in the process because your client is there and you're doing what you love- interacting with clients. It will also ensure that your notes are actually done before your client even leaves. No more worrying about procrastination!

While I want this post to provide you with some very practical tips you can implement immediately, I also want it to provide you with hope

I have been surprised by the number of therapists who tell me they have ADD/ADHD. Now, this could be due to the fact that I specialize in an area likely to cause trouble for counselors with ADD/ADHD but it has shown me there are many of us experiencing the same struggles.

You are not alone. And there are plenty of resources out there to help you. 

Consider doing things like bookmarking my Resources page so you have an easy place to reference helpful thing you may need later on but know you won't be able to keep track of today. Or check out my ebook Workflow Therapy, which compiles all of my time management and systems blogs into one place so you can have an easy resource for organization. 

If you're a licensed counselor or therapist, you may also want to consider signing up for my Webinar CE Club*, which provides you a guaranteed CE credit each month simply for watching my webinars and completing a quiz. No more worrying about searching for continuing education classes at the last minute! Set yourself up and be prepared.
*The Webinar CE Club no longer exists, but you can still access all my tips, trainings, and even more in my Meaningful Documentation Academy.

There are many other tips and resources I could list here! But I'd love to hear what other things you've found helpful for dealing with ADD/ADHD as a therapist or counselor. Share in the comments below and let's show our support for one another. 

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. 

Paper v. Electronic Records: The good, the bad and everything in between

Probably one of the biggest decisions therapists have to make about their practice these days is whether or not to go with electronic records (i.e. EHR). As with anything, there are benefits and drawbacks to this choice. Since I've had a lot of experience with launching electronic health record systems and evaluating workflows I thought I'd lay out all the pros and cons right here so you can make an informed decision about what's right for your practice. Let's dive in...

Paper Records

Pros:

The biggest pro to using paper is that you can start with it practically for free. Create or purchase a paperwork packet, buy some paper and a few file folders and you're set to go. Very little ongoing cost... although you do need to ensure you have a cabinet to lock all files. 

Another pro to using paper is that you can customize and change your forms at will, without worrying about requirements or limitations of an EHR. You can include a logo/branding to make them look nice and delete or add as many sections as you like. 

The third pro with paper is that some people really do have more of a connection with writing something. Also, if you do a lot of worksheets, artwork, etc. with clients in session it is very easy to throw those papers in a file, rather than scanning and uploading everything you want in the client record

Lastly, most people are familiar with paper. It is easy to set up and you don't have to learn anything new to get started. 

Cons: 

The biggest con with paper records is simply that you have to physically store them for so long! Most of us keep records for seven years (or longer, if you see children/teens) and it's really difficult to tell whether or not you plan to move at all in the next seven years. This can also make things difficult to track after multiple moves.

Related to storage is the fact that things can get lost. With paper records, you're really putting all your eggs in one basket and it's very easy to lose things once you start keeping multiple files. 

Another harsh reality is that files can be destroyed or stolen. I know people whose offices have flooded from a leaky sink not caught over the weekend, people whose offices completely burned down in a fire and people whose computer and other equipment was stolen. These things really do happen and it's unfortunate to lose so much information so easily. 

Lastly, many people simply write much more slowly than they type. Using paper records can be more time-consuming than using a computer to complete paperwork. This applies to both your clients as well as yourself and any employees/associates. In some ways, sharing documents can be easier with paper but it can also be more difficult if you need to fax or scan things that would've otherwise already been uploaded electronically. 

The In Between

So... what if you want to type your notes on a computer, but not use a cloud-based system? Perhaps this seems like the easiest solution. The main benefits here are that you likely already have a computer for work, you won't have to lug around a bunch of files or have an ugly cabinet in your office, and you also won't have to pay for a monthly subscription to keep records. 

However, most of the cons with paper still apply here. Your computer is probably the most likely item to ever be stolen and with this method you're likely putting all your eggs in that one basket. So, if anything happens to your computer (and even us Mac users have heard horror stories of people losing everything based on a glitch or a misplaced cup of coffee), well, you're screwed.

Electronic Records

Before we go over any pros and cons with electronic records, it's important to note that while there are some great EHR's out there, no system is perfect and no system will have everything set up exactly the way you want. With that in mind, let's look at what the general pros and cons include...

Pros:

Probably the biggest pro of using an EHR for your private practice is that all your records are easily housed in one place. You simply log in and voila, everything you need! If you have internet access, then you can access your full client records from any location. Many EHR systems even have apps so you can write a quick note from your phone.

Another huge pro is that having your records in an EHR will likely provide the safest records storage available. While we're all concerned about hackers, and that is certainly something to keep in mind, a good EHR will provide excellent security. This security will be far beyond what you could create for yourself, either using paper or keeping notes housed on your computer.

And because you have easy access to safe storage, many EHR's will safely store credit card numbers for your clients. Roy Huggins has a great article (click here to read) discussing the reasons you probably don't want to collect your client's credit card numbers yourself. Having them write their credit card information on a form you keep is very unsecure. But if you use an EHR that has this set up through a merchant account, they are ensuring the security is up to date and you can ensure you'll be paid. 

If you contract with insurance companies, an EHR can save you tons of time because they typically include billing. While that doesn't mean they're going to call to check eligibility or follow up on rejected claims, they will often submit your claims electronically as soon as you enter the necessary data. Again, everything you need in one place. And if you provide clients with a super bill, most EHR's will print out a nice one for your clients based on the sessions you've entered.

Lastly, another benefit to using an EHR is that many offer client portals. This means your clients can log in to complete and upload paperwork before appointments, and even interact with you securely. This can save worry about email communication or clients forgetting to bring in needed paperwork.

Cons:

The most obvious con with using an EHR is the cost. While most are actually providing an exceptional service for the price, it can still be a stretch if you're just starting out and only have a few clients. This is where it's really important to think through all your expenses and also, your long-term goals. Using an EHR is probably one of the best investments you can make for a therapy practice... but if the money's not there, then it's just not there.

Another con is that despite your best efforts and our tech society, there is still a lot of paper going around. This means you are likely to end up scanning documents every once in a while. For some, this may be just a couple pages a year but for others (and depending on your particular EHR set up) it could mean LOTS of scanning. Consider your clientele- do you tend to work with people who often have reports or require lots of communication with other providers? If so, you'll want to consider a more robust system that allows clients to upload documents. Also, if you have an assistant, this may not be such a big deal.

Lastly, another con with EHR's is that some offer limited ability to customize your documentation. You know this is a big one for me because I believe that you should personalize your paperwork to your client's needs as much as possible. Some EHR's do allow you to create your own templates, some don't, and some charge extra for this feature. This is where shopping around and trying things out ahead of time is crucial. The last thing you want is to get everything set up and then realize the notes or treatment plans are a total pain to work with!

Some Cons to All Methods

One mistake I've seen over and over applies to all records, paper or electronic. That's putting something in the wrong client file. I've seen people physically put the wrong note, release form, etc. in a paper file and I've also seen people accidentally type a note in the wrong client's file within an EHR. Some people have never made this mistake, some people have done it multiple times. Obviously, the key here is to make sure you're taking time to be mindful of what you're doing when writing notes. 

An EHR can save you lots of time and headache, but it can't think for you. So regardless of which method you use, make sure that documentation isn't an afterthought. Instead, let's make it a meaningful part of your practice. 

If you're looking for tips on how to personalize your mental health paperwork, check out my free Private Practice Paperwork Crash Course, where I walk you through different ways of writing notes and treatment plans, as well as what to focus on during intake. 

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.

How to Supervise Clinical Documentation

Although some counselors may feel “okay” about their own documentation, few know how to teach this skills to supervisees. And if you struggled with documentation or feel less confident then this becomes even more of an issue.

In this post I’m laying it all out for you… how to train supervisees, how to correct work when needed and how to integrate this teaching into your supervision so it doesn’t take away from the clinical conversations you need to have. So check out the steps below and see if any (or all!) seem like good things to try out with your supervisees.

Reviewing paperwork

1. Read through the notes as a story, not one by one.

The tendency when reviewing notes is to read them week by week for each client. However, when you read only one session note you miss out on the whole clinical picture. Was there something important that was never followed up on? Does the treatment seem to be following a good flow? Have there been any patterns that emerge over time?

2. Check to see if the reason for treatment is clear.

Can you tell, just from reading the assessment and intake notes, why this client is here for treatment? Are you able to identify a clinical need or goals from the client? These should all be evident in the paperwork but should also match your supervisee’s description when you discuss the case.

3. Make notes about what questions come up as you read.

It’s very easy to get caught up in reading a file and forget key points along the way. Use a simple sheet of paper to jot down comments and notes to yourself. Don’t forget to highlight things that are well-written so you can also give positive feedback!

Training on paperwork

1. Write notes together.

One easy way to train is to simply write the notes in your supervision meeting while talking with the supervisee about the session. This allows you to teach them how to summarize and highlight what are the important points while leaving out “fluff” or extraneous details. Another method to this is to watch a sample therapy session together and write notes on the session individually, then share how your notes are similar or different and see what you each focus on. I’ve experienced great success using this strategy with even seasoned clinicians. If you have a group practice or supervise more than one person, this is a great group technique!

2. Talk about treatment planning and how that looks in real life.

Don’t neglect treatment planning with your supervisees. What I find when I talk with therapists about their treatment plans more often is that they tend to adjust them more often. And that’s okay! Check in to see where treatment is going and if things need to shift. That may mean the treatment needs to shift a little to better meet the client’s needs or it may mean the treatment plan needs to be adjusted.

3. Review one file each meeting.

This will insure the notes are getting done, which is a big piece about documentation! It’s very easy for counselors to fall behind in notes but if you’re regularly reviewing at least one file you’re more likely to see a completed file or to at least catch a problem early. This will also create a habit of reviewing files for both of you.

4. Create an action plan for catching up on notes. Keep them accountable to it.

This is HUGE! As soon as even 1-2 notes are missing, make a plan to catch up and check in. As the supervisor, I do believe it’s your job to follow up and make sure this doesn’t become a bigger problem. Be supportive but also create a firm deadline and provide the needed time to meet that deadline.

5. Have your supervisees attend a training. Even better, attend together!

Shameless plug here, I’ve got a couple trainings on this topic, at different levels of intensity. Check out the Meaningful Documentation Academy to see if investing in even just a 45 minute training may help your team. Part of the reason I do what I do is that not many others are doing it so I don’t have a ton of other resources to give in this area, but seek out your local professional association to see if they’d be willing to sponsor a training on clinical documentation. When these do occur, they’re typically very highly attended.

And if you're reading this is a supervisee, suggest some of these with your supervisor! Many supervisors are nervous about documentation as well but if you start the conversation, they are likely to help you out.

Now tell us… what strategies did your supervisor use that helped you with documentation? Any lessons learned that you can share? I’d love to hear in the comments below!

Therapy Notes: A Self-Quiz for Counselors

You’ve maybe heard me talk (or really, write) about feelings and documentation before… I like to normalize a lot of what I hear from therapists. Because I hear it ALL THE TIME.

"I don’t know if I’m writing notes the “right” way."

"I hate writing notes and avoid it but then I get backed up."

Well, in this post I’ve got a tool for you to dig a little deeper and see what it is that’s really causing problems with your notes… and what it is you’re doing well already.

Check out the questions below. They’re all really simple yes/no questions related to how you write notes. No one else is watching so be honest with yourself! And if you want a pretty version to download, click here.

The Self-Quiz

  1. When I sit down to write notes I know exactly what to say.

  2. I know how to calm my mind when my thoughts are racing.

  3. When I think about writing notes I feel calm and confident.

  4. I can easily put into words what “progress” looks like for my clients.

  5. If a client asked to see their records, I would feel comfortable letting them read my notes.

  6. I know how long it takes me to write a case note.

  7. I know what time of day is best for me to reflect and be quiet.

First, let’s analyze what it was like completing the quiz…

What triggered you emotionally? Was there a question that elicited fear, guilt, resentment, anxiety? Take a moment to write down what those feelings are and why.

Acknowledge any prior negative experiences with documentation. Lots of therapists tell me they’ve had a bad experience with a prior supervisor or with having records examined by insurance or requested from a client. That’s okay and it doesn’t have to dictate how you feel about writing notes from now on.

Now let’s check out your answers. Obviously, we’re looking for “yes” answers to all (or at least most) of the above questions.

Was there an area in which you felt confident? What questions were a clear yes? Those are your strengths related to documentation.

And the no’s… are they mostly emotional or logistical? Some people feel okay about their documentation but they need to get the logistics of creating time for writing notes improved. They know what they’re doing for the most part but tend to fall behind easily and then get overwhelmed by the sheer volume.

Others may have a clear idea of the general time it takes and be diligent about writing notes regularly but notes still produce a feeling of anxiety or resentment. You may not feel confident that the content is “up to par” or feel unclear about what should and shouldn’t be included.

Once you have a clearer idea of where to focus your energy (and what to keep doing well) you can take steps to improve it.

Want someone to help you write some notes and actually review them? Schedule a time with a colleague or check out my individual consultation services.

Looking for examples of different types of notes to write? Sign up for my (free) Private Practice Paperwork Crash Course to learn about four different templates to use for notes and see some examples.

Go through your “no” answers and choose just one to work on. See what resources are best suited for that and then take action! There’s no better time to improve your notes than now!!

What’s your next step? Leave a comment below so we can follow up :)

Writing Therapy Notes: The Advice I Give Every Counselor

Do you ever find yourself saying the same thing over and over again? I talk with hundreds of therapists and I certainly find myself sharing the same pieces of advice each month. 

So what better use of a blog than to write down those most commonly given tips on writing notes?! Below are my most common answers when presented with various problems or questions related to notes... 

Choose a theme for the session

Take a moment to think about the main topic you and your client (or clients) reviewed in the session. You may have jumped around to a few different things but don't focus on the minor details. Stick with the general theme and leave the rest out!

Note: Of course, any time there are safety concerns, this rule goes out the window and you want to carefully document your actions. 

Create a regular schedule

Many therapists think they'll squeeze in a few notes between sessions or randomly complete them throughout the week. Ever hear that saying "Fail to plan and plan to fail"... yeah, that totally applies here. Make sure you have time to do your notes that is separate from time you plan to spend on other administrative tasks (like answering emails and phone calls). 

And make your schedule realistic. Do the math to see how much time you'll need. For example, if you see 15 clients per week and spend about 10 minutes per note that is 2.5 hours you should plan to spend each week on notes. 

That's pretty reasonable for most people... but if the thought of spending two and a half hours (or more) on notes each week for the rest of your career makes you want to throw up, consider checking out collaborative documentation for at least some of your clients. You have options, but make sure you figure out what works best for you so you can be successful. 

Simplify your template

Many therapists start out in private practice using all the documentation techniques their previous supervisor used. But (a lot of the time) that doesn't work out so well. I'm assuming you started a private practice to have some freedom in the way you do therapy and guess what, that applies to your notes, too!

Choose a simple template you can use with all your clients and stick to it. If you want to try out a few different ones, I recommend staying consistent for at least 1-2 weeks to see if you like it. Once you get the hang of writing the same way consistently, you'll have to think about your notes less. They'll start to flow. 

If you want some tutoring on various templates and how to use them, check out my free Private Practice Paperwork Crash Course. I go through four different templates- DAP, GIRP, PAIP and SOAP. 

Wait on using check boxes

This is a biggie. Lots of counselors ask me for check boxes, how to create notes with check boxes, lists of interventions, etc. The thing is, I could give you a list with hundreds of options but that would just be overwhelming. And there's no way I can personalize something like that for you without first evaluating quite a few of your notes, your therapy style and getting a sense of your typical client.

So my recommendation is to create the easy template with check boxes later. First, write your notes using a sentence structure and one of the templates described earlier. Then, after you've been in practice for 6-12 months, evaluate all your notes and pick out the common interventions you provide. You can do this exercise in about an hour. 

Do that and you'll have a very personalized list that will truly save you time, rather than searching through some pre-made template where half the options don't apply to you. You can click here to watch my interview with Rajani Levis, a therapist in San Francisco who used this method to create her own notes template. 

Be wary of taking "quick notes"

Many therapists fall into the trap of jotting down a few quick notes to themselves at the end of a session, with the intention to write the full note later, tomorrow, etc. It seems like a good idea initially because you're making sure you don't forget something, knowing you don't have time to write the note at this moment... but this actually creates a false sense of security.

What commonly happens is the therapist holds off on writing notes, thinking they've got everything covered. Then the pile snowballs and five months later they have hundreds of notes to write (yes, literally... this happens a A LOT). 

Obviously, no one wants to end up in the same situation without the quickie notes to remind them of what actually happened three months ago in that one session with so and so. But I have a theory that most therapists who get behind never would have let themselves get to that point if they didn't have those notes as a "safety net." 

Seriously, if you follow these five tips you will find yourself avoiding many of the problems counselors commonly run into. 

"Did she just say commonly run into?" Yup, I did! Because most therapists do fall behind on their notes at some point. And most therapists feel insecure about their note writing skills.

My personal mission is to change all that, for good! I want to make sure we all have the support we need to succeed.

That's why I created the free Private Practice Paperwork Crash Course, write weekly blogs, do monthly webinars (found in the Meaningful Documentation Academy) and all kinds of other things... to eventually replace this fear of documentation with confidence and, dare I say... excitement!

You can also learn more about writing notes (and get 2 NBCC approved CE credits) through my workshop The Counselor's Guide to Writing Notes** or learn some great tips from my ebook Workflow Therapy: Time Management and Simple Systems for Counselor's.

It's a journey, a process, and I'm here with you for the long haul. So make sure you share these resources and let's keep encouraging one another whenever we can. 

Until next time, happy writing!

**The Counselor's Guide to Writing Notes is now exclusively available through the Meaningful Documentation Academy.

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 Review Your Own Notes

At this point I've talked with hundreds of therapists about one topic in particular- writing notes. And I hear some pretty common concerns...

"I feel like I always write too much but I don't know what parts to take out."

"I don't know if I'm including the right information."

"I feel like I spend too much time on writing notes."

Relate to any of these? I've found it's totally normal to have these concerns. And if you think about it, they make sense! 

If you're a licensed therapist you may never have another professional read your notes. Even if you're not licensed, I've found that most therapists receive very little training and review from their supervisors. 

While I do recommend connecting with other therapists to do chart reviews or at least discuss these issues (more on that in the next post), the quickest solution to this problem is knowing how to do a notes review yourself.

So let's break it down in a few easy steps:

Set aside an hour of time to review notes. Any more time and it will feel like a chore and make you overwhelmed but you want to include enough time to do a good review.

Start with one client file and go all the way back to that first intake note. Read through the notes chronologically from oldest to newest. Tip: If this is a long-term client, just go back the last six months or so. 

We'll start with each individual note first. Ask yourself the following questions with each note. I recommend having the questions in front of you so they're easier to remember:

  • Did I describe my own actions (or interventions) during the session?
  • Is my client’s response clear via quotes, observations or an assessment of what transpired?

  • Do I follow up on plans identified in each note?

After that is complete, answer the following questions about the entire file. The key is to make sure all the notes combine to make a clear story.

  • Do my notes provide a clear reason for my client initially entering treatment?     

  • Do my notes provide a clear story of this client’s progress over time?

  • Do I have a note for every date of service provided and explain gaps in treatment (like vacations or missed sessions)?

And there you go... you're now a quality assurance pro! 

I know it may be a little easier to have something in hand or on the screen to view, so I created a neat little handout you can download and print! Yup, you're welcome.

Click here to download your Notes Review Handout.

Your next question may be "But what if I find something is missing? How do I fix it?" Have no fear, the blog is here! Click here to read my article on fixing your notes after the fact.

Still looking for a little more help with your paperwork? Make sure you're signed up for my Love Your Paperwork Challenge**. It's two weeks of daily actions to make your paperwork awesome. And it's pretty epic, if I do say so myself. 

Please comment below and let me know if the Handout helped and share any other tips you have. Happy reviewing!

**This challenge is no longer current, but my Private Practice Paperwork Crash Course is full of tips and tricks that will help you rock your paperwork!

How Do I Document Play Therapy?

How to document play therapy.jpg

One of the things lots of therapists ask me about is how they should write notes when they have a specialization. The quick answer is that you don't really need to do anything differently! But let me explain more...

When you're providing a specific type of therapeutic intervention, that intervention has a purpose. For example, if you do equine therapy you are doing that for a reason. There is something about the interaction that engages clients and makes a clinical impact.

Similarly with something like art therapy or play therapy. When you provide play therapy, for example, the method is different but the purpose is the same. 

You may use dolls to offer reframes or to explain boundaries. You may use a game to encourage positive verbal communication and manage anger. You may use an art project to process trauma or to assess family interaction. 

The point is not really the method. Therapists use all sorts of methods to obtain the same result. CBT, psychoanalysis, the Gottman Method, DBT are all different ways to provide interactions and connect with your client.

Of course, if you do follow a specific method that makes listing your interventions even easier because of the shared language that is common among many methodologies. However, you can apply those same interventions in many ways.

So rather than simply writing "Therapist played with child using figurines" you could write something like "Therapist used figurines in sand tray to assist client with identifying common interactions within the family and practice alternative ways to respond to parents."

Rather than writing "Therapist utilized art therapy with client" you could write "Therapist assigned client art project to identify triggers to anger."

In these instances it's very clear you're not "just playing" but instead are providing clear, therapeutic interventions. 

So the next time you are writing notes for play therapy (or art therapy anything else "Out of the Box") ask yourself why you chose to use that modality. What was the goal you wanted to achieve? And that's what to focus on in your note.

What other tips or pointers do you have? Any further questions? Feel free to drop us a line in the comments below!

And then keep doing all that awesome work you do. 

My Top Tips for Saving Time on Writing Notes

The majority of my one on one clients are dealing with a specific problem that spirals out of control and ends up impacting every aspect of documentation- poor time management.

There are plenty of reasons for this... avoiding documentation out of fear or resentment, not making notes a priority above responding to voice messages and emails, mistakenly thinking that they'll easily be able to remember everything that happened a few weeks (or months) ago... or my personal choice- good ol' optimism and procrastination, thinking you'll have plenty of time tomorrow

I find these reasons become regular habit and are very difficult to battle. However, if you couple determination with proven strategy you can make great progress in overcoming this struggle. 

The determination part I must leave up to you (although I do have some motivation for you in this blog post). However, I can supply the strategy

So here are my top tips for saving time on writing notes (the large bulk of the paperwork you complete):

Schedule your notes

My very first tip is that you MUST schedule in time for writing notes. Otherwise, it will always be something to put off or a dark cloud looming over you. When it's scheduled you feel more secure knowing when the task will get done and you can focus on other things. 

Unfortunately, it's not quite as simple as throwing it in your calendar every week and getting notes done. Many people still hit road blocks and that brings me to my next tip...

Choose the time of day that works best for you

You may have talked with a colleague who writes her notes religiously every afternoon before heading home. Or maybe a supervisor recommended doing them every Friday all day. Or perhaps at an agency you were required to write your notes between clients.

Well, guess what? Maybe that doesn't work for you!

Give yourself permission to try a few things out and determine what really works. For YOU. Trying to fit into someone else's box will never work. 

The "ideal" would be to see a client, write the note, see the next client, write the note. But you know what? I hated that. It just didn't work for me. I need time in between clients to regroup and process without the time constraint and pressure. However, some counselors do this successfully.

You've just got to play around with a few things and see what works. I recommend when you're trying a new tactic that you do it for at least two weeks straight with all your clients. That way you really get to give it a fair shot (like I tried to do with running when I ran that half marathon).

But regardless of which schedule you choose for yourself I also have another tip that applies across the board...

Schedule breaks

Whether you're doing a marathon note-writing session one or two days a week or writing notes in between clients, make sure you take time out on occasion. 

Productivity research shows that people perform better in work "sprints" than marathon sessions. That doesn't mean you need to take a huge break. Just 15 minutes every two hours can significantly increase your creativity and focus. 

So make sure you either schedule breaks between clients or give yourself a break from sitting at your computer writing notes. Take care of yourself and you'll be better equipped to care for your clients. 

And speaking of that, let's move on to some tools that can make the whole task easier... 

Use a dictation software

If you've never been much of a writer and especially if English class was an ongoing struggle for you, I'm going to have a hard time getting you to enjoy writing notes. But you don't have to write!

Try a dictation software and speak your notes. This tactic alone is a life saver for some people. There are plenty of dictation tools out there but Dragon Naturally Speaking is the one I recommend. It's popular with college students who use the software to write essays and is very affordable.

Dictation does take some practice and you may need to go in and adjust things afterward, but getting the note out of your head and on to the screen (or paper) will give you such a fabulous freeing feeling. 

Use an app on your smart phone

There are dictation apps on your phone so you could save "notes" for yourself if you're feeling inspired but not at your computer or with your files. There are also electronic record systems that allow you to write (or even speak) your notes directly into the app so you can be productive while not in your office. 

Of course, I'd recommend you still take some time to reflect and make the notes meaningful but having the app gives you the freedom to write some notes while reflecting at the park or on the beach. Now that's a nice note-writing experience!

And my final tip for saving time is really the ultimate time-saver when it comes to notes, but certainly isn't for everyone...

Try collaborative documentation

Collaborative (or concurrent) documentation is exactly what it sounds like- collaborating with your client to write the session note. So when your client leaves the office your note is either completely or almost completely done. 

You can read my more in-depth look at this strategy in this blog post but I will say that for the purposes of saving time and creating clinical meaning, nothing beats this tactic. It doesn't work for all clients or all therapists but if you really struggle with getting behind on notes, this can save you many headaches and sleepless nights. As with the scheduling strategy, it certainly doesn't hurt to try it out. 

So there you have it! Plenty of tips to create more time for yourself while not sacrificing the meaningfulness or importance of documentation. 

If you want to learn even more tips and cool tricks from me then check out my online program for therapists. It's called Meaningful Documentation Academy and we cover everything you never learned in grad school, all within the confines of a supportive group of colleagues. 

And don't forget to leave a comment here if you try out one or two of these strategies and let me know how it worked out!

Happy writing!!

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.