One way I recommend counselors save time on notes is to choose a notes template and stick with it. In my Private Practice Paperwork Crash Course I review five different types of templates you can use and these are basic copy and paste topics you can use across the board.
However, I do get feedback occasionally that some therapists have adjusted the templates and when they do this, therapists tell me the template is much easier to use and much more meaningful to their work... because it's personalized.
So, I thought I'd review all the different components of common therapy notes templates in case you'd prefer to simply pick and choose what works for you. These components all come from the following note template formats: DAP, GIRP, PAIP and SOAP.
I encourage you to check out what sections appeal to you and seem meaningful to your practice. Choose those and create your own therapy notes template that you'll find easy to use every day.
These are simply listed in alphabetical order, with no identified level of importance.
This section focuses on the clinical assessment of the client's symptoms, progress, presentation, etc. Here you can add more clinical language and also outline how the session may interact with previous sessions or experiences, as well as highlight things you think may be important to monitor.
This is the same as the "Objective" section below (so just choose one). Here you will add information that is objective and behavioral. These are things that occurred in session and any lay person would be able to describe. This could include quotes, acting out, crying, refusing to participate, nervous movements, etc. If it could be heard or seen on a video camera by a person on the street, then it goes here.
This is typically at the top of the note and includes whatever goal(s) the client is working on. Rather than making things complicated, simply copy and paste from your treatment plan wording. Keep it simple and direct, but also monitor to make sure your sessions are really in alignment with the goals you are including with each note.
These are the actions of you, the counselor leading the session. Whether this is something you did passively (like building rapport) or more actively (like teaching a technique), this section is meant to capture where you directed things and how you responded. If you tend to review or teach techniques, direct clients in certain behaviors or challenge and examine thought patterns, this will be an important section for you to include in your notes.
This is the same as the "Data" section above (so just choose one). Here you will add information that is objective and behavioral. These are things that occurred in session and any lay person would be able to describe. This could include quotes, acting out, crying, refusing to participate, nervous movements, etc. If it could be heard or seen on a video camera by a person on the street, then it goes in this section.
The plan is one of the most important components of any notes template and I recommend you have a Plan section regardless of what other sections you include. This is where you identify follow-up, whether that is for you or the client. Here you can clearly identify how the client may incorporate what was learned in session over the next week. And you will also include when is the next planned session. This is crucial for documenting your continuity of care.
Similar to the "Goal" section, the Problem is whatever problem area the client identified they would like to work on in therapy. This may be just as specific as a goal, or may be somewhat vague, such as depressed mood or anxiety. Regardless of the specificity, this will help guide your treatment and allow you and the client to know you are on the same page with where things are headed.
This section is the opposite of the "Intervention" section because it is focused solely on the client and how they reacted to things during session. Similar to the "Data" section you will want to include objective information that would be easily seen or heard by anyone in the room. However, if you choose not to have an "Assessment" section, you may also include more subjective responses made by your client as well. Also, remember that refusing to participate or react to something is also a type of response and should be included here.
This section is opposite to the "Objective" and includes information shared or observed during the session that is either subjective to you or to the client. This could include things like a prognosis or an interpretation of a response. It could also include subjective statements made by the client themselves.
So, how does this all look if we put it together in new formats? You'll notice that some sections are similar and I never recommend duplicating your work, so choose what you like best to have a complete note.
Some examples could be:
PDAP (Problem, Data, Assessment, Plan)
GOAP (Goal, Objective, Assessment, Plan)
PIRP (Problem, Intervention, Response, Plan)
PIRAP (Problem, Intervention, Response, Assessment, Plan)
SOIAP (Subjective, Objective, Intervention, Assessment, Plan)
The amazing thing about being a therapist in private practice is that you get to make these decisions! Don't let it overwhelm you, let it make you a better clinician by personalizing things to yourself and your clients as much as possible.
One last recommendation is to consider using one format for ongoing notes but a different template for assessment. A participant in my Meaningful Documentation program did this and found it was much easier for her to write the more in-depth assessment note for the first session but then she could take things down a notch going forward.
Play around with things and see what works for you. Don't make it too complicated but also understand that sometimes creating these systems does take time. However, once you have a clear format for writing progress notes you are able to do them much more quickly and with less mental effort.
That way you can spend time on what is most important- the clinical work!
Leave a comment below and let me know what you decided if you choose to mix and match. I'd love to hear and so would many of your colleagues!