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.

Supervision Notes- Practical Tips for Staying Sane and Organized

Like most notes, supervision notes aren't a big deal until they ARE a big deal... meaning, when you need them! Until then, they sometimes feel pointless and often feel annoying to do.

But you don't have to know much about me to know my schtick- which is making documentation meaningful, simple, even nearly enjoyable!

I'm currently a supervisor for licensed clinicians and I write regular supervision notes so I can remember what's going. Being disciplined about regular notes is key. It's so easy to get behind and then you're playing with fire... because it always seems like that's the time when something "bad" happens.

But it's about more than just writing your notes each week or month... it's about the organization and content, too. So I thought I'd share with you some tips on how to keep organized with your supervision notes so they stay awesome.

Write on a Schedule

While I find it nearly impossible to write a therapy note right after the session, it's not the same for me with supervision notes. I typically do these right after or at least that same day. 

This way I'm never worried. When someone (like HR, yeah, that's happened frequently!) asks me for more info I already have it all laid out for whoever needs it.

This is much easier because my supervision sessions aren't weekly, so I don't feel like I'm constantly writing notes.

Keep it Simple

With supervision notes you can really stick with the bare minimum. I don't really worry about the amount of time we met or where we met. I make sure to include dates and what we discussed. That's it. 

As with everything, there's no black and white rule here. For example, if I had to deal with an employment issue or a crisis I will go into more detail. But if we discussed some standard cases, time off and reviewed a training then that's all I need to write. I save my time typing for the big stuff and then I go into detail.

Be Organized with Files

It took me some time to figure out filing because again, no one teaches you this stuff and there's no specific standard. I do all my notes on the computer and each supervisee has a file. In the file I have a Word document (because this is my day job- at home I use my lovely Mac) that is a running file of supervision notes for the year. 

Each day or meeting is a bullet point. I list the date and then my notes are in sub-bullets. That keeps things very easy to review at a later time as well as organized. 

Did something come up outside of supervision? Did I communicate some important message and want to track when that happened? I list that as a bullet point as well. Easy peasy.

In the file for each supervisee I also keep any pertinent documents. Another thing that's been super useful is to save emails in that folder. For example, perhaps you communicate a new protocol or respond via email to an important situation, save that email in the supervisee's folder. 

This tactic alone has saved me soooo much time! I used to waste a lot of time searching through my inbox folders for things. Another strategy is to simply name a folder in your email inbox for each person you supervise and use that to house all correspondence. This works well if your email traffic is lighter. 

And voila! You've now got an easy way to keep your supervision notes. They're easy to retrieve should you ever need them and easy to review if you ever want to revisit something. 

Leave a comment below with your own tips for writing supervision notes. And if you're still struggling with this whole documentation thing, remember that you can always reach out for individual help from me. Just click here to find out more.

Documenting Consults: Protecting Your Assets

I've had a few therapists ask me recently about how to document a consultation with other psychotherapists. "When do I need to do it?" "What should I include?" "Where does the note go?"

My biggest piece of advice is first, to actually DO it! Many counselors in private practice don't think about how this simple task could save lots of trouble down the line. It doesn't have to be intense or scary (we'll get into that below), but it can be super helpful. 

So, let's get into the What, When, Why and Where of writing a consultation note...

Why

Documenting consultations with other professionals serves a few purposes. Firstly, it proves that you took action to be ethical. Some ethical concern came up and you took the appropriate action. Without documentation, how can your prove that happened? Answer: You can't!

It also helps you clinically. It's impossible to remember everything that goes on with your clients or even with your professional growth. However, if a situation ever comes up a second time, you now have a previous decision documented. You can go back and review without relying on your unfortunately, very fallible memory.

When

I recommend documenting a consultation with a colleague any time the issue is impacting the clinical work or any time it's an ethical concern. You may be part of a regular consultation group and do case presentations. It's not necessary to document each of those instances... unless it meets criteria A or B above.

There are times when ethical dilemmas arise in the moment and you don't have time to consult before you need to take action. These situations are also an excellent opportunity for consultation. Discuss the possible actions you could have taken and get feedback on how to proceed from that point on.

What

Now we're digging in... what in the world do you include?! If you only take away one thing from this post, focus on this word- rationale. The purpose of a consultation is really to document the discussion around the rationale for your decision. 

Include who you talked with and which ethical principles apply. Identify why you needed this consultation. Describe the action you will take and more importantly, the reason for your decision.

Maybe your client shared a significant issue in the last session and it's an area in which you're totally unfamiliar so you consult with a colleague to determine if you need to refer out to a specialist, continue treatment with supervision, or simply review some resources.

Perhaps your client presented you with a pricey gift (let's go with... a Caribbean cruise) and you graciously did NOT accept. Your client seemed miffed and you'd like to consult on how to proceed at this point because you have not had this experience before.

Or maybe your client is requesting ALL of their treatment notes out of the blue. You feel this could be harmful for them and want to be prepared when talking with them about it. You want to make sure you are considering all the laws, ethics and clinical issues at play. 

Note: A distinction is made here with countertransference issues. Often, issues will come up that prompt us to seek our own process and work through our own emotions. Although this does impact your clinical work, the distinction here is that the focus is on you. In some situations you may actually seek consultation as well as your own therapy. 

Where

Now that you've got this excellent consultation note, where the heck does it go? As long as it's specific to the client and a clinical issue with them, put it in their client file. If it's specific to yourself (this would be rare, but you never know!), create a consultation file and put it there. 

Consultation notes = easy... right?! 

Our work is so meaningful and often fun but the unknown, the scary, and (gasp) mistakes are bound to happen. That's where documentation comes in to save the day (cue super hero music). 

Just be your wonderful, ethical self and write about why you're doing what you're doing. Easy peasy. 

Still not totally comfortable with the whole note-writing thing? Check out my free Private Practice Paperwork Crash Course. I talk a lot about notes and even give you some samples to look over.