Step-by-Step Intake Progress Note

Did you know that your very first progress note should look different from your other client case notes? 

That's because the first session with clients, the intake assessment, is very different from our "typical" sessions... whatever "typical" looks like to you ;) 

In that first session with mental health clients we have forms to review and information to gather. And there are very important things to discuss with our clients so they understand the counseling process.

I recommend including that you reviewed all of these things in every intake progress note you complete (obviously, with the understand that you actually did review those things with the client in session):

  • Limits to confidentiality
  • Potential benefits and drawbacks to treatment
  • Consent for treatment
  • Attendance policy
  • Communication outside of session
  • Reason for seeking treatment
  • Assessment of symptoms
  • Assessment of biopsychosocial data
  • Plan for treatment

Some sections may have more or less detail, depending on the client's situation or length of the session.

For example, it often takes more time to do an intake for child and adolescent clients because we want to get information from the caretakers, as well as the client. Others simply do a more in-depth assessment and take 2-4 sessions. 

When that happens, simply document the portions you did cover (and with whom you discussed it) and then what you plan to cover in the next session. However, I do recommend that you review limits to confidentiality and obtain consent at the first session, whenever possible.

Want to see an example note?

I've got one for you! Check out this sample note below to see how it looks when we put it all together. I'm using the DAP note format here...

Data: 

Client arrived early and had completed intake paperwork online using client portal. Reviewed with client the limits to confidentiality, potential benefits and drawbacks of treatment, communication outside of session and attendance policies. Obtained consent for treatment. Discussed biopsychosocial history further and completed all intake paperwork. Assessed reason for treatment, current struggles and symptoms. Identified goals for treatment. Current goals include 1) Creating a routine for relaxation and self-care and 2) Identifying priorities and planning for work and home tasks accordingly. Client requested weekly assignments to stay on task so we will use this format to start and evaluate after 6-8 weeks. 

Assessment:

Client was comfortable disclosing details about prior treatment and mental health history. Exhibits excellent insight and desire for continued personal growth but is frustrated with ongoing struggles and feels she is not meeting her potential. Previously treated for both depression and anxiety, for which she has created excellent coping strategies and continues to use cognitive-behavioral techniques to address. Currently struggling with symptoms related to ADHD as primary concern.

Plan: 

Client will attend weekly sessions in the office, with the option to move to online sessions if needed. Therapist will assist client in identifying the appropriate weekly “homework” tasks before the end of each session. Client will provide one check-in via journaling in client portal once per week outside of sessions. Weekly assignment is to gather all to do lists and pending tasks to bring in for next session and label with priority level. Next session scheduled for 05/19/17 at 12pm.

You're probably thinking, "Does my note need to be that detailed?"

Maybe not... that all depends on the situation, as well as how in-depth your intake assessment is. For example, if you don't use homework or if you didn't have time to review treatment goals, this note would be a lot shorter.

On the flip side, if you had to do an assessment of safety because the client reported feeling suicidal, your note might actually be longer

Notice that this note doesn't include anything I would have in my intake assessment form.

That's because I see no reason to write the same thing multiple times!

This used to drive me crazy when I worked in an agency. And it's a reason that soooo many therapists resent paperwork and fall behind. That's why I recommend you streamline your documentation as much as possible. 

If you have questions about substance abuse, past treatment, relationships, and suicidal ideation then why do you need to write these things over again in your intake note? My opinion is that you don't need to duplicate this... but you do need to have it documented somewhere that makes sense.

So, if you miss something on your intake assessment form then write it in your intake progress note and vice versa. 

I've got a checklist you can download to create your own intake note template or to use as a reminder when writing your intake notes.

Enter your info below to sign up for my weekly emails and then check your inbox to download the checklist! Remember to check your spam or junk folder.

We keep your information secure via our Privacy Policy.

Therapy Notes: Your FAQ's Answered

therapy notes faq.jpg

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!

The Mountain of Paperwork in Community Mental Health

Mountain of Paperwork

Clinical documentation- mention it to most therapists working in community mental health and they will cringe. Along with that word comes mental images of being flooded with redundant paperwork, staying late to write progress notes (or worse yet, working from home), and having supervisors identify endless corrections needed. Few clinicians or supervisors will tell you they enjoy this aspect of their job. Fewer still will tell you they felt prepared for the demands of government-contracted requirements through their training in graduate school. Yet, ask any therapist with a client who has attempted suicide and they will tell you (perhaps begrudgingly) this is one of the most important aspects of their work. 

Clinical documentation is invaluable when we need it most. Progress notes document our efforts to contact clients exhibiting high risk behaviors. Consultation notes document  standard of practice and a rationale for our actions when “grey areas” appear. Mental status exams and assessments document the client’s history of symptoms and provide a course for treatment. Clinical documentation is a necessary tool for therapists working in the revolving door of community mental health. 

However, many therapists find the paperwork difficult to maintain. They don’t see the connection between the clinical work and the forms they’re required to complete. They feel drained and overwhelmed by the daily paperwork requirements. 

If you are a clinician working in community mental health and find yourself becoming overloaded with paperwork, try following some of these steps:

  • Prioritize your paperwork according to it's importance.
  • Talk with your coworkers to see what tips they find useful.
  • Do your best to keep interactions with your coworkers positive.
  • Decide from the beginning that you will NOT fall into the trap of “fudging” the time you bill by 10-20 minutes here and there.
  • Be honest with yourself regarding your strengths and weaknesses.
  • Engage in self-care.
  • Stay connected with your colleagues.

Make sure you talk with your supervisor from the beginning about your struggles to get the support you need. Seek out extra training and consultation. Your agency may offer refresher trainings or, if you’re in the L.A. area, you can check out the upcoming workshop I’m doing on documentation (trust me, I try to make it as fun as possible!). You can also sign up for the QA Prep Newsletter (and get access to my free paperwork crash course) to get tips on making documentation easier and more relatable. 

Don’t be afraid to evaluate different job options if you find you’re a round peg trying to fit into a square hole. When you’re less stressed, you’re providing better care for your clients. Keep the focus on being the best therapist you can be- in all aspects of your work and don't be afraid to ask for help when you need it. Happy writing, everyone!!