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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Therapy Notes: Your FAQ's Answered

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Dealing with notes from months ago.

Worrying about notes sharing too much information if revealed in a legal proceeding.

Spending too much time writing notes because of worries about insurance audits.

These are the concerns many counselors share about their case notes. 

I've been collecting a database of questions I commonly receive and figured it's about time I focused on answering some of these! So, this will be the first blog in a series focused on FAQ's. 

Remember that my goal is never to tell you exactly how to do something. I am a strong believer in multiple correct answers or ways of doing things (in most circumstances). But I do hope to offer you some food for thought in my answers below.

These are all real questions or concerns brought up by other therapists... and I hear them over and over again:

 

Writing Notes Late

"How late can I write notes if I'm behind?"

You can (and I would say, should) write any note that isn't written. That means if the note is from last year, write it! If it's from last month, write it! There is no expiration date on writing notes.

Now, if you're like me, there may be an "expiration date" for your memory. And there are certainly expiration dates for things like insurance claims, so that's another story. But having a complete story in your client's record is always important. 

I do recommend that if it's been a long time (this is subjective but let's say more than a month), include something like "Late Entry" at the top of your note. 

You're not trying to hide anything and since you should sign and date all notes on the date of entry, that won't match your session date. This is simply providing an explanation for why those dates are off.

 

"What can I do if too much time has passed since the session and I don't remember anything to write as a note?"

Sometimes this happens. And it sucks. 

Do what you can but NEVER make up information that you don't remember. 

If you honestly can't remember what happened but you're certain your client did show up for the session, write a very brief note like...

Late Entry. Client attended session. Addressed treatment goals. Next session planned for xx/yy/zz.

Is that a good note? Of course not. But let me tell you, it's still better than no note at all and you're not compromising your integrity. Admit that the situation sucks, create a plan so it doesn't happen again, and move on. 

 

How Much To Include In Notes

"I feel I write too much... that is how I remember things actually. Should I then do a summary for the legal notes?"

I feel the same way! As I've mentioned before, part of the reason I stay on top of notes is that I know I have a horrible memory and won't be able to write them a week later if I got behind. 

I recommend asking yourself some key questions while writing:

What was the theme of our session?

What stood out to me as important about our session? 

What seemed important to my client during our session?

What do I want to follow up on? 

What do I think will be really important to have written down for later?

Try to keep your answer to each of those questions to one sentence, then use that as the basis for what you include in your notes. This process may take a little more time initially, but you'll be able to train yourself to think about these things when you sit down to write notes.

The process will get easier and faster over time. And you know what? You may simply write a little more in your notes than another therapist. And that's okay.

And if writing a lot or taking a lot of time on notes is a concern for you, I actually don't recommend you write a summary for the "legal" notes. (This would mean writing freely as process notes and then writing a summary for the progress notes- see the section  on HIPAA below for the difference.)

Why is that? Because then you'll create more stress for yourself and spend even more time on notes! Not what we're going for here. Simplify things instead.

It's okay to have objective information in your notes. We worry a little too much about having "too much information" in our progress notes. But if you want some more guidance on how to pare things down, check out this blog post where I give an example of how to do that.

 

"How much specific detail do you include regarding session details and/or thought process in how you arrived at a decision?"

Here's a vague answer you'll hate- however much it takes to explain your rationale.

Seriously though, if you're in a situation where you're documenting why you made a clinical decision, you're likely dealing with something that could potentially be high risk or an ethical dilemma or the like. This is NOT the time to skimp on information!

Provide the applicable laws or ethical principles, information from research or consultations you did, and how all of those things contributed to your decision. This is the basis for your rationale. 

Sometimes this can be accomplished in 1-2 sentences, sometimes it will take 1-2 paragraphs. It simply depends on the situation. 

 

Insurance Worries

"I'm finding myself writing 1-2 page progress notes. Since I've started taking insurance, I've become stressed with note taking."

Notes for clients using most insurance companies aren't drastically different from notes for clients who pay privately. The biggest difference with insurance is that you want to consider medical necessity. 

I have a much more detailed blog post on this topic here, but I can summarize by saying that you do want to make sure you're following a treatment plan that is focused on the client's diagnosis and you want to address two things in every note:

  1. Progress made
  2. Ongoing need

This is the fine line with insurance. If therapy isn't helping your client in the long-term, they may choose to no longer pay or not to approve further sessions. However, if you only focus on progress then it appears your client no longer needs services.

Insurance is often not concerned about your specific interventions or treatment modality (although it does apply in some cases). They simply want to see that they are paying for a service that is meeting the member's needs. 

And yes, they usually do want to see how they can do that more cheaply. Let's be real. 

So make sure you consider that, too. How is ongoing therapy keeping your client from deteriorating, from needing more intensive treatment? How is it improving their health or relationships? These are all things that make therapy a very cost-effective treatment when compared to things like hospitalization or tests for somatic presentations of symptoms. 

 

"How to document in a problem focused way to satisfy insurance, disability, etc when the session is strength based and optimistic."

Continuing our discussion from the answer above, you want to include honest information about the progress (or lack therof) that your client is making, as well as their ongoing need. 

I definitely work from a strengths-based perspective, but that doesn't mean I'm ignorant to the reason my client is seeking therapy.

They have a concern and that manifests itself in ways that are impacting them negatively. To gloss over this or pretend it's not a concern is actually quite demeaning, disempowering and invalidating.

Documenting this and addressing it is a critical component of enacting change and working through any problem. Documenting this does not place blame on the client or invalidate any of their strengths. In fact, it does quite the opposite.

So yes, include the strengths and the wins. Absolutely. 

And then also include what continues to be a concern, a problem, a need. Identify what didn't work or continues to be a struggle. Document the full journey your client is on and you'll have a beautiful narrative that highlights their resiliency and strength throughout. 

 

HIPAA & Psychotherapy Notes

"What are psychotherapy notes based on HIPAA?"

This is a BIG topic and for a more complete answer, I'll direct you here to an article from Simple Practice's blog. But here are the basics with psychotherapy notes per HIPAA...

  1. Psychotherapy notes are what we commonly refer to as process notes.
  2. Psychotherapy notes are optional and MUST be kept separate from the client record to receive their distinction.
  3. Psychotherapy notes are NOT progress notes (case notes) that discuss ongoing treatment.

Why they decided to use such a confusing term, I'll never know! But per HIPAA, psychotherapy notes are those optional notes you might write to yourself about sessions, clients, to jog your memory, etc. As such, they receive special privacy and clients are typically not entitled to them. 

However, these never take the place of progress notes, which are the ethically and legally required notes we do need to take. 

So yes, if you choose to write process/psychotherapy notes, you are choosing to write two different notes for sessions. For some therapists, this is a really important part of their own process. For others, it is simply an extra burden and they choose not to do it. 

In case you're wondering, no, I don't write process notes. But I also share notes with my clients on a regular basis, so I often do things a little differently ;) 

 

"It appears that process notes can also be subpoenaed. How do we keep non clinical notes for our memory sake?"

Yes, they can! It is a common misconception that process notes (psychotherapy notes as discussed in the previous question) receive such special treatment they cannot be subpoenaed. 

However, it is very rare that psychotherapy notes are ever subpoenaed and I would guess that if they are, whomever is requesting them is often intending to request progress notes instead. It is always best to call your client and discuss the reason for the subpoena, see if they are providing consent to release records, and to then assert privilege when applicable. 

Unfortunately, since the definition of psychotherapy notes is basically any notes you take about clinical treatment for your own purposes, I can't think of a way to ethically do that so they are never potentially subpoenaed. 

Remember though, that process notes can be whatever you want them to be. That means you can use abbreviations, shorthand, your own illegible handwriting... whatever you want! You do not have to worry about these notes being ready for scrutiny. 

That being said, the one thing I would encourage you to consider is how your client may react if they saw the notes. Although it is highly unlikely that will ever happen, you wouldn't want to have anything that could be offensive. I'm not saying to avoid writing things that are true, but do consider how you word things. 

 

What do you think about these situations? You may have another great suggestion or factor to consider. Let us know in the comments!

How My ADD Helped Me With Paperwork

Believe it or not, I was recently diagnosed with ADD. The reasons I was never diagnosed before now are clear. I've always received very good grades, was a genuinely good kid who never caused any trouble, am generally a responsible adult and... I've always been great with paperwork at any job I held.

While receiving the diagnosis was a huge relief for me to explain reasons I've had difficulty with many other areas of life, I began to question how I've been so successful with documentation. Yes, ADD looks very different in each person, but paperwork is supposed to be an almost universal problem for people with this diagnosis! How come it was never a problem for me?

After reflecting on this for quite some time I realized that many aspects of my ADD actually worked to my benefit in completing therapy notes. For real. Let me explain.

Below are some common problems associated with ADD/ADHD that I found I have been using to my benefit this whole time:

Procrastination

Now, this may seem really counterintuitive, but the fact that I regularly (meaning, ALWAYS) procrastinate pushed me to create very firm deadlines for myself when completing paperwork. I know that I can put something off for a really long time. And in my early years as a therapist, I actually had very little supervision regarding documentation, so it was up to me to create deadlines or become extremely backed up. 

While it wasn't easy, I focused on discipline and made sure that I scheduled in time for writing notes and completing assessments. I knew if I didn't schedule it, something else would inevitably take up that time and then, as described in the next reason, I would not be able to produce a quality note. 

Poor Memory

To put it bluntly, I have a horrible memory. So poor, in fact, that if I didn't write my notes within 24-48 hours, I would never be able to write them at all. The sooner, the better for me... and everyone else!

However, I do NOT write notes in between sessions. That just never worked for me. I need the break in between because I've just spent a good amount of energy keeping focus on my client and I need to recharge before the next one.

I either write notes in the session or the following morning, before starting the rest of my clinical day. That way I am able to feel ready for the day ahead and close out what was pending from before... and know it's accurate.

Hyperfocus

Here's where I truly used some ADD traits to my advantage. As many others with ADD/ADHD, I am able to hyperfocus for very long periods of time on things that are of interest to me. So, if I don't write notes in session, I write them in large chunks. That means I rarely sit down to write notes for 10-15 minutes. It's usually more like 45-60 minutes of getting everything done at once.

This means I don't have to pull attention away and I can get in the zone for writing. And because I know that distraction is around every corner, I'll often close my door and shut off things like email during these times.

I create an environment that encourages me to hyperfocus on the task and get it done.

Enjoyment

Some of you may be thinking, sure you can hyperfocus if you like something, but what if you don't like a task... like writing notes?! Well, the key is to find something about it you do like. If you've taken my free Crash Course, you know I talk about creating meaning in your notes and preparing yourself for writing notes.

I literally choose to enjoy the task. First, I know it's a really important thing to do and that helps to motivate me in the beginning. Secondly, I look at writing notes as an opportunity for me to reflect on the clinical work. I view it as a time for me to sit back and see things from my client's point of view or to make sure I'm staying on track with our overall goals. 

It's never a time to just sit down and write notes that mean nothing. This is the time for me focus on my client's session one last time and make sure I've closed any open doors. 

Tips for Dealing with Paperwork for Counselors with ADD/ADHD

Maybe some of the things I've described above help you to see things a little differently or give you some helpful tips to try. But there are plenty more ways to deal with paperwork if you're a therapist with ADD/ADHD. You can also try some of these strategies below:

  • Choose a time that works for you. Make sure the time you're writing notes works to your strengths. For example, I focus better in the morning so that's when I'll write notes... or blog posts ;) 
  • Get accountability. It's scary to admit to another professional that you've gotten behind in paperwork. However, all of us therapists know that talking about something when we feel fear and shame is the best way to overcome those feelings. Even if it's simply shooting me an email, tell someone about the help you need.
  • Incorporate exercise or movement. If you tend to have difficulty sitting still for long periods of time, don't! Write a note, then do 10 push ups or squats. Write another, repeat. I've done this when reviewing paperwork for other people because it keeps me engaged and helps me focus.
  • Try collaborative documentation. If writing notes is a significant point of stress for you, write as much as possible in session with clients. This accomplishes a few things... it will actually help you to be more engaged in the process because your client is there and you're doing what you love- interacting with clients. It will also ensure that your notes are actually done before your client even leaves. No more worrying about procrastination!

While I want this post to provide you with some very practical tips you can implement immediately, I also want it to provide you with hope

I have been surprised by the number of therapists who tell me they have ADD/ADHD. Now, this could be due to the fact that I specialize in an area likely to cause trouble for counselors with ADD/ADHD but it has shown me there are many of us experiencing the same struggles.

You are not alone. And there are plenty of resources out there to help you. 

Consider doing things like bookmarking my Resources page so you have an easy place to reference helpful thing you may need later on but know you won't be able to keep track of today. Or check out my ebook Workflow Therapy, which compiles all of my time management and systems blogs into one place so you can have an easy resource for organization. 

If you're a licensed counselor or therapist, you may also want to consider signing up for my Webinar CE Club*, which provides you a guaranteed CE credit each month simply for watching my webinars and completing a quiz. No more worrying about searching for continuing education classes at the last minute! Set yourself up and be prepared.
*The Webinar CE Club no longer exists, but you can still access all my tips, trainings, and even more in my Meaningful Documentation Academy.

There are many other tips and resources I could list here! But I'd love to hear what other things you've found helpful for dealing with ADD/ADHD as a therapist or counselor. Share in the comments below and let's show our support for one another. 

The Comprehensive Note Writing Guide for Therapists

I've written quite a few blog posts on notes over the past few years. Side note: In case you're feeling overwhelmed by the thought of blogging or starting something new, I never thought I'd have this much written by now! Keep at it and be consistent :)

Anyway... I wanted to put what I consider some of my best tips for writing notes all in one easy-to-find spot. Below are articles I've written here on QA Prep, as well as some other gems I've written for other people's sites. 

See what applies to you and check out the related article. Notice something you'd like to work on at some point in the future? Schedule it in your calendar now and bookmark this page so you can follow up when you have time to focus

Reviewing and improving your notes is an ongoing process. Don't feel like you have to do it all at once or learn everything right away. But if you don't schedule it and make that a priority, it's likely one of those things that will fall by the wayside. So take 30 seconds to schedule that time right now.

Let's dive in...

Questions to ask yourself when writing notes

It's always nice to have some guidance when sitting down to write notes. In this article I outline four questions you can post somewhere to ask yourself before writing notes. This helps to put you in the right mindset and keep the content something you can be proud of. 

Consider who may read your notes

There are actually many people who could potentially read your client's case notes. In this article I review the three people who are most likely to do so and how to consider what each may be looking for. 

Create your own notes template with check boxes

A lot of people ask me about creating check boxes for the notes in order to save time. In this article I outline a sure-fire process for doing this in a way that will still capture the individualized needs of your clients, as well as your unique ways of providing therapy.

Choose a notes template that works for you

Although I talk about some common notes templates in my free Private Practice Paperwork Crash Crash, this article gives you a quick read with similar information. I review four common notes templates and how they may apply to your counseling practice. 

Figure out how long your notes need to be

In this article I give you an example of both a short and long note and we evaluate what type of information we can remove in order to make things more efficient. This article is especially helpful if you feel like you write too much in your notes and want to cut things down.

Review your notes to see how you're doing

In this recent article I share some strategies for how to review your documentation. This is something I think is very helpful when you're feeling stuck with a client, as well as when you're ending treatment or writing summary letters. 

Write notes that make insurance companies happy

Notes don't necessarily need to be very different if you contract with insurance panels, but there are things you consistently need to think about with your documentation. In this article I outline the most important things to focus on if you think an insurance company may want to see your notes some day.

Identify ways to save time on notes

Most therapists are looking for ways to save time when writing notes. While I do encourage you to make documentation a meaningful part of the clinical process, efficiency is always a great thing! In this article I give you a variety of strategies for saving time on notes... and you can try out most of them right away.

Catch up on notes if you've gotten behind

It's a horrible feeling to get behind in your notes. Overwhelm takes over and it can be very difficult to find a way to catch up. In this article I share a five step process for catching up on notes, no matter how far behind you are!

There you have it! A comprehensive list of how to improve your notes and think about them a little differently. If you'd like more help with notes and documentation in general, you can check out my online workshop The Counselor's Guide to Writing Notes**. I love seeing how people's fear of documentation shifts after they can see some examples. 

You can also check out my ebook, Workflow Therapy: Time Management and Simple Systems for Counselors. It's a compilation of my best tips and blogs on improving your efficiency and managing all the paperwork related items in your practice.

So whether or not I see you online or in person, happy writing. 

**The Counselor's Guide to Writing Notes is now included with membership to the Meaningful Documentation Academy.

Paper v. Electronic Records: The good, the bad and everything in between

Probably one of the biggest decisions therapists have to make about their practice these days is whether or not to go with electronic records (i.e. EHR). As with anything, there are benefits and drawbacks to this choice. Since I've had a lot of experience with launching electronic health record systems and evaluating workflows I thought I'd lay out all the pros and cons right here so you can make an informed decision about what's right for your practice. Let's dive in...

Paper Records

Pros:

The biggest pro to using paper is that you can start with it practically for free. Create or purchase a paperwork packet, buy some paper and a few file folders and you're set to go. Very little ongoing cost... although you do need to ensure you have a cabinet to lock all files. 

Another pro to using paper is that you can customize and change your forms at will, without worrying about requirements or limitations of an EHR. You can include a logo/branding to make them look nice and delete or add as many sections as you like. 

The third pro with paper is that some people really do have more of a connection with writing something. Also, if you do a lot of worksheets, artwork, etc. with clients in session it is very easy to throw those papers in a file, rather than scanning and uploading everything you want in the client record

Lastly, most people are familiar with paper. It is easy to set up and you don't have to learn anything new to get started. 

Cons: 

The biggest con with paper records is simply that you have to physically store them for so long! Most of us keep records for seven years (or longer, if you see children/teens) and it's really difficult to tell whether or not you plan to move at all in the next seven years. This can also make things difficult to track after multiple moves.

Related to storage is the fact that things can get lost. With paper records, you're really putting all your eggs in one basket and it's very easy to lose things once you start keeping multiple files. 

Another harsh reality is that files can be destroyed or stolen. I know people whose offices have flooded from a leaky sink not caught over the weekend, people whose offices completely burned down in a fire and people whose computer and other equipment was stolen. These things really do happen and it's unfortunate to lose so much information so easily. 

Lastly, many people simply write much more slowly than they type. Using paper records can be more time-consuming than using a computer to complete paperwork. This applies to both your clients as well as yourself and any employees/associates. In some ways, sharing documents can be easier with paper but it can also be more difficult if you need to fax or scan things that would've otherwise already been uploaded electronically. 

The In Between

So... what if you want to type your notes on a computer, but not use a cloud-based system? Perhaps this seems like the easiest solution. The main benefits here are that you likely already have a computer for work, you won't have to lug around a bunch of files or have an ugly cabinet in your office, and you also won't have to pay for a monthly subscription to keep records. 

However, most of the cons with paper still apply here. Your computer is probably the most likely item to ever be stolen and with this method you're likely putting all your eggs in that one basket. So, if anything happens to your computer (and even us Mac users have heard horror stories of people losing everything based on a glitch or a misplaced cup of coffee), well, you're screwed.

Electronic Records

Before we go over any pros and cons with electronic records, it's important to note that while there are some great EHR's out there, no system is perfect and no system will have everything set up exactly the way you want. With that in mind, let's look at what the general pros and cons include...

Pros:

Probably the biggest pro of using an EHR for your private practice is that all your records are easily housed in one place. You simply log in and voila, everything you need! If you have internet access, then you can access your full client records from any location. Many EHR systems even have apps so you can write a quick note from your phone.

Another huge pro is that having your records in an EHR will likely provide the safest records storage available. While we're all concerned about hackers, and that is certainly something to keep in mind, a good EHR will provide excellent security. This security will be far beyond what you could create for yourself, either using paper or keeping notes housed on your computer.

And because you have easy access to safe storage, many EHR's will safely store credit card numbers for your clients. Roy Huggins has a great article (click here to read) discussing the reasons you probably don't want to collect your client's credit card numbers yourself. Having them write their credit card information on a form you keep is very unsecure. But if you use an EHR that has this set up through a merchant account, they are ensuring the security is up to date and you can ensure you'll be paid. 

If you contract with insurance companies, an EHR can save you tons of time because they typically include billing. While that doesn't mean they're going to call to check eligibility or follow up on rejected claims, they will often submit your claims electronically as soon as you enter the necessary data. Again, everything you need in one place. And if you provide clients with a super bill, most EHR's will print out a nice one for your clients based on the sessions you've entered.

Lastly, another benefit to using an EHR is that many offer client portals. This means your clients can log in to complete and upload paperwork before appointments, and even interact with you securely. This can save worry about email communication or clients forgetting to bring in needed paperwork.

Cons:

The most obvious con with using an EHR is the cost. While most are actually providing an exceptional service for the price, it can still be a stretch if you're just starting out and only have a few clients. This is where it's really important to think through all your expenses and also, your long-term goals. Using an EHR is probably one of the best investments you can make for a therapy practice... but if the money's not there, then it's just not there.

Another con is that despite your best efforts and our tech society, there is still a lot of paper going around. This means you are likely to end up scanning documents every once in a while. For some, this may be just a couple pages a year but for others (and depending on your particular EHR set up) it could mean LOTS of scanning. Consider your clientele- do you tend to work with people who often have reports or require lots of communication with other providers? If so, you'll want to consider a more robust system that allows clients to upload documents. Also, if you have an assistant, this may not be such a big deal.

Lastly, another con with EHR's is that some offer limited ability to customize your documentation. You know this is a big one for me because I believe that you should personalize your paperwork to your client's needs as much as possible. Some EHR's do allow you to create your own templates, some don't, and some charge extra for this feature. This is where shopping around and trying things out ahead of time is crucial. The last thing you want is to get everything set up and then realize the notes or treatment plans are a total pain to work with!

Some Cons to All Methods

One mistake I've seen over and over applies to all records, paper or electronic. That's putting something in the wrong client file. I've seen people physically put the wrong note, release form, etc. in a paper file and I've also seen people accidentally type a note in the wrong client's file within an EHR. Some people have never made this mistake, some people have done it multiple times. Obviously, the key here is to make sure you're taking time to be mindful of what you're doing when writing notes. 

An EHR can save you lots of time and headache, but it can't think for you. So regardless of which method you use, make sure that documentation isn't an afterthought. Instead, let's make it a meaningful part of your practice. 

If you're looking for tips on how to personalize your mental health paperwork, check out my free Private Practice Paperwork Crash Course, where I walk you through different ways of writing notes and treatment plans, as well as what to focus on during intake. 

Feeling Stuck With a Client? 3 Ways Your Documentation Can Save the Day

We've all been there. That moment in session where you realize you've had this same discussion with your client before and it ended up nowhere. That moment you see a family or couple bringing up exactly what they seemed to have already worked through. That moment you find yourself searching in your mental toolbox but come up empty-handed.

That moment where you have nothing to say and are having difficulty finding hope in the situation yourself.

While these situations are uncomfortable and often disconcerting, they hold huge potential for growth and change. But as with most obstacles that seem like a 12 foot wall, these situations usually require a different strategy in order to overcome.

What's the awesome strategy I have for you in these difficult clinical situations?

Do a review of your client's file.

Before you stop reading, let me explain!

Usually when you come across these clinical scenarios it's after you've done some work with your client. These situations don't typically pop up in week one or two because you're getting to know your clients, they're motivated to change and your plethora of clinical tools are at your disposal. 

But for those times when it's months later and your toolbox hasn't proved as helpful as it normally is, this little trick can be a game changer. 

Because now you are looking at your client with different, more experienced eyes. 

Have you ever had a situation happen where things weren't making sense and then someone offered you some insight... and when you looked back on things you realized all the signs were there early on but you just couldn't see them yet? That's what your documentation can do for you, offer that critical insight.

1. Go back to the very beginning.

Look at your client's intake paperwork. How did they present when they first came in? What did they identify as their main problem? Did they identify goals? 

Also notice if anything seems missing. Perhaps their original paperwork denied substance abuse but you discovered otherwise later on. Perhaps they noted a happy family situation but have talked about nothing but being unhappy in their marriage for the last three months.

Is there anything that pops out at you as unusual or noteworthy now that you know client more? If so, perhaps there is something you can bring up in your next session to change the cycle of repetition or feeling stuck.

2. Evaluate your treatment plan.

Do you have a treatment plan with your client? If not, this is a great time to start one! Talk about their goals, ways in which they feel they have progressed and what they would like to see happen in the future. 

And whether or not you already have a treatment plan, this is a great time to ask about how counseling is going. Do your clients feel things are going well? Does it feel like anything is missing?

If you've already got a treatment plan going, bring that out in session to check in. Are you both on track? Does this plan still make sense? Are there things either of you could be doing differently to help achieve these goals?

Make it a conversation but don't be scared to actually have a treatment plan written out and share it with your clients. This is where the paperwork can be a great catalyst for insight.

3. Review your notes from day one.

Lastly, start with the very first note in your client's file and read through chronologically. What stands out to you? What progress has been made? 

Any topics you find coming up again and again? What were the plans related to those topics? Was there follow through on any homework or plans?

Try to be as open in this process as possible. There may be something that jumps out at you right away that you've never noticed before. There may also be behavior you realize you're enabling or something clinical you realize you've missed and should address.

Really focus on conceptualizing your client's case and how to best meet their needs. This will certainly bring up questions or ideas you can address with them in the next session.

"But Maelisa, I did this and realize my notes are so minimal they don't really give me much information."

That's okay! First, take that as valuable information and adjust your note writing a bit (from now on) to include a tad more detail. Second, ask your client to help you fill in any gaps! Not literally on paper, but start your next session with an overview.

Ask your client about any sessions they found particularly meaningful or any times they felt resistant to things you discussed. Perhaps you can create a "best of" list or a "most helpful" and "least helpful" list. This is a non-threatening way to talk openly about what works and what doesn't and to review treatment overall.

If you're feeling stuck with a client and try this technique out, let us know in the comments below! And if you want more help on using your documentation as a clinical tool, check out my upcoming workshops (inside the Meaningful Documentation Academy) or try using my paperwork packet. Sometimes it takes a little trial and error so be kind to yourself but keep at it. Your clients will thank you. 

What I Learned (about paperwork) from the Road to Success Summit

I had such a great time putting on the Road to Success Summit in June and I learned soooo much from all the experts I interviewed. It was pretty cool to do the interviewing because that means I aaaalllll the content!

I knew the Summit would be helpful for therapists in private practice and my goal was to cover as many different areas as possible. But there was one thing quite obviously missing... a lesson on paperwork!

So, I thought I'd take this opportunity to highlight how your documentation relates to everything in your private practice. And if you're interested in an opportunity join the LIVE version of the Summit, click here to find out more.

Below are the lessons I learned from all the experts who participated, and how it relates to your paperwork:

Casey Truffo and being the CEO of your private practice

-Casey dropped some major knowledge bombs about business in general and has such an easy way of explaining things. The big thing I got related to paperwork was to outline everything you do. Take the time to write out your process so you can later improve, refine and duplicate when needed.

Kelly Higdon and integrating coaching into your practice

-Kelly talked about the differences between coaching and therapy. One of the big differences was the intention behind the service you plan to provide. You might actually be working on the same area (stress at work, for example) but choosing a different way to focus together. And that means, your paperwork will look different! Kelly pointed out that with her coaching clients she actually takes notes during the session and sends them the notes. I do this with my individual consultations as well. We cover a lot so this way the client can stay focused!

Keri Nola and using your intuition in your private practice

-Keri and I talked a lot about the finer nuances of using your intuition in every part of your practice. I think this applies to your paperwork, as well. Don't just include things because you feel you have to, think about how you'd like to write. Never seen something in someone's intake packet but feel led to include it? Then do so! Listen to your heart as well as your ethical guidelines.

Jo Muirhead and creating a successful money mindset

-Money was the topic of Jo's interview and we discussed a lot of the ways we misperceive things and sabotage ourselves by often avoiding the topic. I see a lot of therapists uncomfortable with money and that impacts client care. Because if you're not able to create a clear plan and decide how much you need to charge to sustain your practice, you'll end up reducing your rates out of fear (and often telling yourself it's really out of client need). However, if you have a clear plan that's represented in your policies then that frees you up to provide pro bono or discounted services to those who need it without feeling resentful

Camille McDaniel and adding clinicians to your practice

-Camille brought up some excellent points about hiring and planning ahead. One of things this highlights is being really clear about the conditions of employment ahead of time and also very clearly outlining any conditions of subletting your space. One example she brought up was making sure her subletter's clientele was similar to her own so there weren't potentially awkward situations in the waiting room. 

Rajani Venkatraman Levis and building your practice through community, not competition

-Rajani is one of my favorite people on the planet. That has nothing to do with paperwork but I just want you know how awesome she is. Anyway, Rajani talked about the power of reaching out to others for support, without worrying about whether or not they might be your "competition." It's so crucial to have regular access to some clinicians whose opinions you value so that you can receive feedback when needed. Changing your forms or not sure how to write something up? Call someone you trust so you can talk it through!

Roy Huggins and using technology to serve your clients

-If you know Roy, then you were not surprised that this interview was packed full of extremely useful info! He talked about how the internet actually works and why that means it's our job as a counselor/therapist to review with our clients any risks with technology. Make sure you have a statement in your informed consent about those risks and then document reviewing them with your clients.

Melvin Varghese and starting a podcast 

-Melvin shared some very practical steps for how to start a podcast, as well as the tools he uses for his own successful podcast. He also talked about monetizing his podcast recently and how valuable it has been for creating authority and networking with other professionals. How does this relate to paperwork? Well, do you have a place for clients to write down where they found you? This will help you to gear your marketing efforts toward what is working best. And maybe, that's a podcast!

Ernesto Segismundo and using video to promote your practice

-Okay, I'll be honest, it's difficult to tie this interview into a documentation lesson. But you know what? I think Ernesto really highlighted why video is such a powerful tool. What if you had a video on your website explaining your intake process, rather than just telling people to download forms? The more interactive and personalized you can make things, the more your clients will appreciate that effort. And boy, will it make you stand out as going the extra mile!

Kat Love and creating a beautiful website

-Kat shared insight into how to create a website that is appealing your clients. This is huge because you're competing with all sorts of distractions online. Since my focus is on making your documentation meaningful to both you and your clients, this really begins with your website copy and presence. Make sure everything flows together smoothly. Use a lot of casual language and pretty colors on your website but then have very stoic sounding forms that are all black and white? That's a mismatch! So continue your branding from website to forms to service.

Clay Cockrell and providing counseling online

-Clay provides counseling online and also runs a directory for other therapists who provide online services. Since this whole online counseling thing is so easy for him, he shared sooooo many resources and tips! One big tip? Create a plan for what you'll do when technology fails, because it will at some point. If you're providing counseling online, include this in your informed consent form or create a separate document that explains what you'll both do (for example, will you call the client or should they call you?). This can decrease any stress that may occur, for both you and your clients.

Barbara Griswold and responding to insurance inquiries

-In Barbara's interview we talked about dealing with insurance companies and she shared a lot of the mistakes she sees therapists make. One of the big things is thinking they don't need to worry about insurance ever seeing their paperwork. Although it's not super common for insurance companies to audit your files, it does happen. And the way in which you document can impact whether or not your client's services will be rejected. So, even if you're just providing a super bill, make sure you're well informed about what's needed.

Samara Stone and building a practice based on insurance

-Samara talked about why it's important for her to have a large practice that bills insurance and also shared some of the mistakes she made early on when using insurance. One of the biggest mistakes was being unfamiliar with the billing process. Once she decided to suck it up and learn what was needed she was able to make sure billing was going smoothly. And, that allowed her to know the right person to hire when she needed to outsource that task because of the time it was taking. 

Nicol Stolar-Peterson and creating a court policy

-In Nicol's interview I tried to start off with "what do we do when we get a subpoena?" and Nicol let me know we had to back up first! Why? Because responding to legal requests and whether or not you get paid to do so is all about what you have in your court policy. So make sure you've outlined that ahead of time and don't get caught losing money while waiting around in the courthouse just to assert privilege. 

Agnes Wainman and identifying your ideal client

-Agnes talked about why it's important to identify an ideal client and then actually walked me through some exercises to do that. But marketing isn't where this stops. Make your intake paperwork speak to your clients, as well. Continue that relationship from whatever made them call you to them completing their forms and walking in your door to the two of you working together. If your forms are personalized to their needs, they'll immediately feel a sense of relief for taking the step and reaching out to you. 

Allison Puryear and networking your way to success

-Allison and I talked about how you can choose networking strategies that are specific to your personality and work with your strengths. Wondering what to talk about when you meet with other therapists for networking? Ask them what type of notes template they use! Trust me, most counselors are actually interested to talk about it because they're dying to hear what you do, too!!

Stephanie Adams and creating systems that sustain your practice

-And we're back to where we started... with systems! Stephanie focused on the ways in which creating systems for her practice has saved her time and stress. One of the first systems I recommend you automate and really spell out is your intake system. How do you give clients info in the beginning, how do they sign and read forms, how do they pay you, will you remind them of their first appointment and when, etc. Writing this all out will save you a lot of stress in the long run.

If you didn't get a chance to watch all the interviews, then check out the interviewees who sound the most useful to you. They ALL have great resources to be used at different points in your practice.

Also, make sure you're signed up for my weekly newsletter so you never miss info on awesome stuff like this! I've got a few things planned coming up, including some live workshops across the U.S. You won't want to miss it!

10 Tips for Documenting in Crisis

In the wake of the Orlando shooting, I noticed questions popping up about how to obtain consent and document therapy when providing crisis services. My goal is to support you in the awesome clinical work you provide so I've compiled a list of tips for how to proceed quickly so you can get in there and be a support for others.

Two common ways in which this occurs is that you'll either volunteer services through an agency or organization of some sort, or you'll offer to provide services in your office. Since these situations present different responsibilities on your end, I've separated the tips out. 

If you're providing services through a crisis center/agency/other organization:

  1. Ask. Make sure you check in with whomever is in charge to see what is expected of you. Is there a brief form you should have people fill out? Where should you write a note documenting whom you saw and where does that note go?
  2. Make suggestions. It's very common that systems and procedures are not set up in crisis situations. This is your opportunity to provide a nice suggestion. Offer to use your own note template or informed consent language. Offer to meet with other counselors and determine a protocol. Take a leadership position if necessary, because people are counting on you to be the professional.
  3. Document anyway. In some situations you may be encouraged to be more lax. While I agree this isn't the time to split hairs, crisis situations don't give you a free for all. You're still a professional with ethical guidelines so even if someone in charge wants to give you a pass, write up a note anyway.
  4. Be timely. No matter how chaotic things may be, do any required documentation immediately. It is too easy to get caught up in the whirlwind around you and then forget what happened with the 9th person you saw that day. Be responsible and take the time to get notes done. 
  5. Check in re: follow up. Make sure you have a clear sense of what will happen after you meet with someone. Is this a one-time debrief or an opportunity to connect with more ongoing counseling? If you feel someone needs additional services, where do you recommend they go? Set yourself, and the people you will meet, up for success rather than disappointment or abandonment. 

If you're providing services in your office:

  1. Reduce and reuse. Go through your intake and consent documents and identify what is the bare minimum information you need to review with someone before proceeding. Crisis likely isn't the time to go through your social media or texting policy, but you do still want to establish some boundaries and expectations.
  2. Explain yourself. When you choose to do the minimum necessary, it's important to explain why. Use your progress notes to explain why you chose to leave out certain things. This is your chance to provide your rationale.
  3. Be timely. Do these notes right away. When emotions are high it is very easy to forget specifics, even though you think there's no way you'd be able to forget such details. Even if you're behind on notes for other clients, do these crisis notes NOW.
  4. Be clear about follow up. Clearly identify with the client and clearly outline in your notes what the plan is for follow up. Is this a time-limited or session-limited series you're providing? Are you meeting with someone in the absence of their own therapist and planning to provide a connection at a later time? Or is this potentially a new client for you? Additionally, you'll want to be clear about who the client should contact (and how) should they feel the need outside of your session.
  5. Revisit when it's appropriate. If you end up seeing this client more long-term, it doesn't mean you get a "pass" for reviewing all that stuff you originally omitted in the beginning. After a few sessions, revisit those things (like your cancellation policy, etc.) that may not have seemed so crucial in the crisis moment. No need to ruin a good therapeutic relationship because you both weren't on the same page two months later.

Of course, crises are as wide and varied as the people involved in them, but these tips can help you have some order and direction in what is often a chaotic situation. 

What other tips do you have for documenting in a crisis situation? Share in the comments below and let us know what has worked well for you... or even what didn't work well and you'd never do again!

3 Big Problems Therapists Had in 2014

You know how your clients often get stuck coming in and talking about the same problem session after session? You review with them strategies you've previously discussed or you process why the same patterns seem to continue across relationships and circumstances. And, while every person is unique, you begin to see common themes emerge.

Well, in 2014 I started QA Prep because I noticed therapists asking lots of questions related to clinical documentation... and I started to see patterns emerge. The same questions, over and over again. And I thought, "what if I developed resources for therapists so they didn't have to search all over for answers?" I opened shop in April and spent a lot of time answering emails, responding to questions in Facebook groups and problem-solving over free consultation calls... and here are the main things therapists had problems with in 2014:

Time Management

Did you know the majority, yes the vast majority, of your colleagues struggle to keep up with their paperwork? If this is a struggle for you, you are not alone! This is one of the most common and one of the most destructive problems I see. When therapists think documentation is boring and meaningless, they avoid it or do sloppy work. And once you're behind by one day, it's easy to push things back further... and before you know it, you're a whole month behind on documentation. And then the paperwork to be completed looks like a huge mountain to scale.

The game of catch-up, fall behind, catch-up, etc. becomes a vicious cycle and creates a lot of resentment toward documentation. 

The key is really to be honest with yourself and create a realistic plan. Don't do what your previous supervisor told you worked for them or what the therapist down the hall is doing. Do what works for you! Some people choose one day per week to do all their paperwork, some do notes for every individual in the 10 minutes between sessions, some do notes for an hour at the end of the day. These are all possible strategies to try. The "best way to do paperwork" is whatever works to actually get it done. I would recommend at least creating a weekly plan so that by the end of the week you know everything is complete and don't have to catch up later. 

Insurance

I consistently get a lot of questions about insurance, relating to reviews by the insurance company, how to write notes and treatment plans for insurance, and what CPT codes to use for different sessions. Honestly, the CPT code questions are the most common and also the easiest to answer! Here are the top three...

Q: What code do I use for couples counseling?

A: For insurance and coding purposes there is no such thing as couple's therapy, there is family therapy. Use the family therapy code, 90847, when doing couple work and clearly identify why the marriage counseling is assisting the individual client with his/her mental health needs. This still requires the individual to whom you are billing insurance to have a diagnosis. 

Q: Does insurance cover teletherapy and what code do I use?

A: The answer is, it depends. Some states have required insurance companies to reimburse for telehealth services but some have not. Furthermore, the requirement does not set a standard for payment, meaning the insurance company may reimburse teletherapy at a different rate from your in person sessions. The key is to know whether or not your state is included in this list and to check your individual contract with the insurance company. If you are able to provide teletherapy, use the regular therapy codes with a "GT Modifier."

Q: Does insurance cover (insert service or code here)?

A: Again, the answer is, it depends. Every contract with an insurance company is unique, meaning the therapist in Suite A may be contracted to bill seven different codes/services at a specific rate and the therapist in Suite B may be contracted with the same insurance company to bill nine different codes/services at a different rate! This means the answer to any question about what you can bill lies in your contract. Do not rely on your colleague's experience in this area, make sure to look at your individual agreement. As a side note, this also means that yes, your rates are negotiable... if you want them to be!

Staying Up to Date

Lastly, another concern that is common is figuring out how the heck to stay up to date. Many therapists feel pretty competent in their documentation but after 15+ years in practice they are unsure whether or not they're up to date. Documentation is not a common topic to discuss, especially among seasoned clinicians, and it's easy to start feeling as though you may be missing something. 

The obvious is answer to this dilemma is taking continuing education classes, especially in areas such as ethics, HIPAA, and clinical documentation. Also, join your local and/or state professional association. Their job is to stay abreast of changes in mental health and update their members accordingly. Interestingly, I first heard about the 2013 changes to CPT codes from the California Psychological Association, not my agency or connections while working in quality assurance!

However, another great way to stay up to date is through consultation with colleagues. Choose a trusted colleague and discuss one to two cases together and how you do your paperwork for that case. Better yet, choose a colleague who has recently attained their license and then another colleague who has 15+ years experience. You can also review 1-2 of your client files ahead of time and come with questions. It's a great learning experience and you'll likely gain a few helpful tips from one another!

If you're not sure how to get started with a consultation group, sign up for my monthly newsletter (and get immediate access to my free Paperwork Crash Course), where I review tips on this and other ways to improve documentation. I take a totally judgement-free approach in all my material and I'm always creating new programs for therapists who want rock solid documentation. 

Share in the comments below any other struggles you think are common and we'll problem-solve together!

Like the tips in this blog post? This blog is part of the compiled tips in the ebook Workflow Therapy: Time Management and Simple Systems for Counselors.

Why Medical Necessity is Important to Private Pay Therapists

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In a previous blog I talked about the term Medical Necessity. Most of you are probably thinking, “Well, that only applies to people who work with insurance companies.” While it’s definitely crucial for people billing to insurance to understand those aspects, I think every therapist needs to have a good understanding of medical necessity. Here’s why:

  1. If your client has insurance and eventually wants to use that insurance for treatment, they will need to show they meet medical necessity. You can never predict if your client may choose to use their insurance. Even if you don’t plan to bill for them or continue services at that point, it will help them tremendously if you can give them (and maybe, their new therapist) an idea of how they meet medical necessity.
  2. Medical necessity is a term used in medical circles. As mental health professionals, it is important we are able to use the same terminology as medical professionals. We need to be able to speak the same language as physicians if we want to work with them in providing quality care and use them as a resource for referrals.
  3. Using the key points of medical necessity is a great way to conceptualize cases! Ethically, we need a clear understanding of our client’s needs and how we can help them. We also need a way to determine if treatment is effective and when it is no longer necessary. Additionally, if you have difficulty conceptualizing a complicated case, try using the medical necessity formula. It will help you narrow your focus. You can see the formula in my previous blog, What is medical necessity and why do I care?

Although private practice therapists are able to have a lot more flexibility in their documentation, using the concepts of medical necessity can help us to use consistent language as a profession and improve our communication with other practitioners, such as physicians. Rather than seeing the term as a box within which we are stuck, we can simply add the concept of medical necessity to our toolbox and resources list.

Are you interested in finding out more about private practice documentation? Sign up for the QA Prep mailing list and get immediate access to my free paperwork crash course.

The biggest paperwork mistake therapists make

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This is going to seem like the simplest advice you’ve ever read, but if every therapist were actually implementing it, I wouldn’t think it was important to write about. The biggest paperwork mistake therapists make is not writing things down.

This could be due to lots of reasons- not having enough time, not understanding what’s important to write about and what’s not, or even choosing to keep certain information out of a client’s chart so it “won’t hurt them later on.”

When writing notes on your sessions and interactions, keep the information really basic, simple, and elaborate whenever you have that “gut” feeling that something was off. This could be a phrase that struck you as odd or out of the norm for your client, even if it wasn’t a clear threat. It could also be something more glaring, like a client’s passive suicidal ideation and any steps you took to ensuring your client is safe.

Another important thing to document (that is sooooo often missed) is things outside of session. A family member calls and leaves you a message about the client’s recent behavior. The client calls you two days after your last session to say “I’m wondering if this is really working out.” A social worker contacts you about a child client you’re seeing because a child abuse report was made by the school.

None of these are things that happened during your session, but they are all just as important to document.

Make sure you are clear about basic things like dates, times and names of who you interacted with but also about why you’re doing what you’re doing. If you’re presented with a grey area, consult with a trusted colleague and write a note explaining your reasoning behind your actions.

Ultimately, you are much more likely to regret a lack of documentation than over-documenting. If you take away anything from this article, or from anything I say ever, take away this: If it’s not written down, it didn’t happen!

Seriously, post it next to your computer or notepad as a constant reminder so your actions are never called into question. And for those sticky situations where you feel you really need help and don't know what to do, schedule a consultation or check out the resources available on the QA Prep website. Happy writing, everyone!