One Quick Tip for Better Paperwork

No, really! How many times have we seen those ads at the bottom of a page or on Facebook? The “one secret” that will make the weight melt off, the “one thing” you shouldn’t eat, the “one trick” for cutting bills in half…yeah, right.

But this isn’t a trick or a secret.

This is a legitimately quick tip that will ease your mind if you’ve ever worried about your paperwork being reviewed in an audit, or by a lawyer or even your client.

If that sounds like you, this is going to help you feel a lot better about your paperwork. 

>> One of the most important things you can do, that’s often overlooked by therapists, is document getting informed consent right from at the beginning of your work with someone.

I’m not talking about getting your intake form signed, because most people are really good about that. Even if you’re not reviewing the form with people, you probably have it signed.

What I’m talking about is taking the next step to CYA.

First, make sure you really are reviewing the intake form! You can’t have informed consent if you’re not…informing people, right? Reviewing the form gives you a chance to highlight important topics like your cancellation policy or limits to confidentiality, the things that can potentially become problems down the road, and answer any questions clients might have.

I do want to remind you that informed consent is a fluid process, not a one-time thing you do and never address again.

So if you miss something it’s not a big deal, you can just go over it another time.

But it’s not good enough to just go over consent and have someone sign a form. You want to document it in your intake note.

I know. You’re thinking I’m documentation obsessed. You’re not wrong, but hear me out because this will take so little time and has fantastic payoff.

When you write your very first progress note from your very first session, you want to make sure you include all the regular progress note info, and you also want to write something like, ‘reviewed intake packet with client.’

Write down specifics like:

• Reviewed limits to confidentiality and potential benefits and drawbacks fo treatment.

• Discussed fees and cancellation policy.

• (If needed) Reviewed limits to confidentiality between adolescents and parents.

  And finally …

• “…and obtained consent for treatment.”

Of course you might have other things in there that are important to note because it will depend on your practice, the client, and the session. But MAKE SURE you document that you did review the forms with your clients AND you got their consent to treat them.

It’s just a few extra lines in your note, but it shows clearly that you started treatment exactly the way you’re supposed to, and it will give you extra confidence in your paperwork from day one.

If you’re looking for other tips on making your paperwork better, check out my free crash course or head on over to the Meaningful Documentation Academy for full access to all the best information and trainings to help you love your paperwork.