This is a supervisor’s worst nightmare, but it’s also a fairly common scenario: You find out (usually inadvertently) that a clinician you supervise hasn’t been writing therapy notes.
You want to take immediate action, but what options do you have? Your options depend on a few important things, such as:
Is the supervisee licensed or working under your license?
Are you supervising this person while employed at an agency, or is this a private practice setting?
Is the supervisee an independent contractor or an employee?
Important Side Note: The regulations for each of these vary greatly depending on both your state AND your profession (e.g. psychologist versus professional counselor) so not all of these options will apply to everyone.
Let’s look at this scenario from a couple viewpoints and divide them into Independent Contractors and Employees so we can look a little bit deeper…
Options Based on Employment Status
Important Side Note #2: I am NOT an employment attorney and am giving general advice based on what is common in most mental health practices. You should definitely consult an employment attorney in your state about this topic if you’re dealing with this scenario.
Independent Contractors & Therapy Notes
If the therapist who is behind on notes is an independent contractor, rather than an employee, one option is to make sure that your contract with this person states a complete progress note is part of the service provided. Therefore, no payment is made until notes are complete.
This doesn’t totally solve the problem because the person could still choose not to write notes and not to get paid (yes, I’ve seen this happen), so you’ll also want to identify in your contract:
Who is in charge of keeping and maintaining client records and
What timeframe is acceptable for completing notes
This gives you options to determine whether or not you want to continue hiring this person, and grounds for making such a decision.
For example, you may not be as concerned if the therapist is fully licensed and maintaining their own records. While this is certainly not ethical practice, your personal liability may be much lower in this scenario.
Let’s play out a somewhat common scenario where you likely have very little (or no) liability:
Perhaps you are an LPCC with a private practice and you have a psychologist who is an independent contractor and provides psychological testing. You have an agreement that they maintain all their own records but since you are referring them clients, your clients typically provide a Release of Information so that you can obtain a copy of the final testing report. In this scenario, you likely have little to no liability if the psychologist isn’t doing their job and writing notes. You might choose to stop working with and referring to this person, but that’s aside from a liability standpoint.
Let’s play out a somewhat common scenario where you likely DO have a good amount of liability:
Perhaps you are an LPCC with a private practice and you are supervising an unlicensed clinician who pays you to sign off on their hours (FYI- this is where circumstances get state and profession specific). You meet with them regularly but you honestly didn’t think to talk about progress notes and this supervisee never asked. Then one of their clients requests a copy of their records and the supervisee confesses there are no therapy records because the supervisee hasn’t been writing progress notes. This scenario can play out many different ways at this point but many clinicians would immediately point to the supervisor and ask why records and progress notes were not discussed previously.
Employees & Therapy Notes
In some ways, you likely have more power to manage this situation if someone is an employee.
You can choose everything about your policies and procedures and then enforce them accordingly. That means you identify what constitutes a progress note, how long people have to write therapy notes, what progress note template they use, what is included in a progress note or process note, where the clinician writes therapy notes, etc.
However, you typically have to continue paying them for catch up time writing progress notes if they are an employee (since most state laws will require payment for time while someone is working).
At this point, your only decision is how to enforce your policy and what consequences this supervisee will experience.
Ideally, your policies and procedures will spell out exactly what should happen in this scenario because, guess what? It WILL happen to you at some point.
So the key progress notes policies and procedures you want to have in place are:
Have a clear policy (and/or IC contract) about when notes are due.
I know you want me to tell you what is acceptable here. ;)
I recommend a policy that notes are due either 24 or 48 hours after a service is provided.
Have a clear policy about what happens when someone falls xx number of days behind in notes.
I’ll offer another recommendation here: An action plan needs to happen when someone is a week or more behind in notes. This is a tipping point for many clinicians and allowing people to get more behind negatively impacts EVERYONE involved.
Have a clear policy about what is included in a progress note and which scenarios require progress notes (e.g. phone calls and voice mails).
Have a clear policy regarding how often supervisors review notes and/or check that notes are completed, regardless of whether they supervise people who are licensed or unlicensed.
Yes, supervisors need policies, too!
If you are working with Independent Contractors, identify who owns and maintains the mental health records.
Document any training you provide on writing progress notes, record keeping, etc.
Document ongoing conversations about reviewing progress notes, improving progress notes, being behind in progress notes, etc.
If you discover a training need (e.g. a clinician is behind in writing therapy notes) document the plan for that clinician, including a due date and what will happen if therapy notes are not completed by the due date.
I find the difficulty here is NOT in the policies and procedures themselves. It is in the enforcement of the policies and procedures…
Yes, that means the problem really lies with the fact that the supervisor didn’t know what was going on and found out too late.
Again, this is super common and the situation sucks for everyone involved. But as a supervisor, your role is to learn from this and improve things for everyone moving forward.
Here’s what I recommend if you discover a supervisee is behind on writing therapy notes:
Have a very honest conversation with the clinician about their struggles. Many therapists have so much shame around this topic. Offering support and encouragement can often be the catalyst for change, because no one wants to be so behind.
So many therapists feel powerless in this situation. Focus on empowering this clinician with resources and TIME to get caught up.
>> But also provide extremely clear and concrete boundaries and progress markers… and then FOLLOW UP.
What Are The Potential Consequences For Not Writing Progress Notes?
The potential consequences for the supervisor are mostly ethical related and based on whether or not this is reported (either by someone in your agency or practice, or by a client who requests records which end up not being available). So, if no one ever needs anything there could potentially be no consequence at all. If the Board found out, then consequences likely range from a reprimand to temporary license suspension (although that’s totally dependent on the Board).
The potential consequences for your practice or agency include fines or penalties (if a client requested their records and none were available), loss of funds (if there were an audit, depending on your current revenue streams and the requirements thereof), and/or a potential case with the supervisor in question.
The potential consequences for the supervisee are also mostly ethical related and based on whether or not this is reported and if so, to whom… and then, what action (if any) that entity chooses to take.
>> However, this is where things can get a little tricky because although most of us would probably agree that even an unlicensed person should know they need to write progress notes, this kind of thing can sort of be turned around in some cases. Meaning, the supervisee may turn around and have an argument that they were not clear about policies, that there were no policies at all, that they received no training and/or supervision, etc.
This is why your policies and procedures, as well as documenting that you have reviewed these with people, are paramount in this situation.
You know what else is paramount? NEVER assuming that ANYONE has been trained in documentation or feels comfortable with documentation.
The sad reality is that dozens of therapists admit to me every year that a supervisor has shamed them for their progress notes at some point in their career. If you are a clinical supervisor and reading this, please don’t be that supervisor!
Instead, provide expectations, boundaries, and guidance.
If you’re a clinical supervisor and feel ill-equipped to offer guidance on documentation (another common scenario I see!), then check out my trainings and pass this info on to your supervisees.
Trust me, they’ll be relieved if you bring up the topic, and even admit you have apprehension about it yourself!