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.