My Supervisee Isn't Writing Progress Notes! What Can I Do?

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:

  1. Who is in charge of keeping and maintaining client records and

  2. 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.

#leadershipequalstakingresponsibility

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!

Group counseling notes: What you need to know

Are you a therapist who recently decided to start a group, or is even just considering it, and then thought, “Wait — How do I write the note?”

I’m here to give you the basics so you feel confident documenting those group therapy sessions.

The first thing to remember is that group notes really aren’t that different from individual therapy notes. Phew, right? So breathe deep and relax, because you can do this. The notes are pretty much the same and some parts are *exactly* the same, and that will help you save time.

The biggest difference in individual therapy notes from group therapy notes is that you need to document the individual interactions AND the group interactions. And the good news about THAT is: it’s pretty easy.

Step One:

Follow your normal progress notes template. Whichever one you use — DAP, SOAP, GIRP, PAIP, or your own format — and make sure you include all those components in how the individual client acted, how they interacted with the group, how the group reacted to and interacted with them, how they influenced the group, and how the group influenced them.

It sounds like a lot, but I promise, it really isn’t.

Step Two:

My biggest advice for therapists writing group notes is:

DON’T WRITE ANYTHING TWICE!

This means you can sort of “cheat” a little in group notes, and this is where you start saving time. How? Well as you work with the group you might provide an intervention for the whole group, and you definitely don’t need to write that five or ten times. Write it once, and then copy and paste into everyone’s individual note.

I heard that little sigh, even through the computer.

Yes, you do still need to write individual notes for each member, because they are each still individual clients and should have separate therapy records.

So you’ll have a portion of the note that deals with the whole group, interventions you provided, the things you did that apply to everyone, and another few sentences specific to that client.

Easy enough, right?

Use your template and take advantage of those little tricks to save yourself time: Copy and paste what you can, and then add the individual components highlighting how the group is different for each person.

That’s it. You’re done!

Are you doing group therapy? What tips and tricks do you use?

If you want more information on the notes templates listed above, or aren’t feeling confident with your individual notes yet, check out my FREE Private Practice Paperwork Crash Course.

For more in-depth help with writing progress notes, check out the Meaningful Documentation Academy, which is full of trainings on notes, treatment planning, time management, and more.

The 2 Biggest Blocks to Writing Progress Notes

Today I’m going to tell you a juicy secret.

What kind of secret? I’m going to share the two most common things I hear from therapists about what blocks them from writing their progress notes.

I know you’re thinking that if I hear it all the time, it’s not a secret, right? Well it’s a secret therapists keep from each other, and I’m here to air it out so we know we’re all dealing with the same issues.

Issue #1

FEAR

Yup, fear. Fear is a huge block. Lots of therapists become paralyzed when they sit down to write progress notes because they don’t know what to write.

They worry about who will read a note and what they might say about it. Even if a therapist has never had a note critiqued, never had a negative comment, never had a note read in court, so many are afraid that those things are lying in wait, just around the next corner.

People sit down to write, or they think about writing, and this fear actually stops them from writing altogether.

Other things therapists are afraid of are audits or client record requests. The idea of a client reading progress notes, even if they’re written, can be terrifying. Embarrassment about the idea of notes making people look bad or un-professional can also keep therapists from writing case notes or being as thorough as they should be.

Issue #2

PERFECTIONISM

This is huge for a lot of therapists, people who have Masters or Doctorate Degrees, so they are used to doing things well! And when it comes to notes, we don’t typically get a lot of training in writing notes, and there isn’t a lot of information out there about writing notes, or even a general criteria therapists can refer to if they want to be sure they’re covering the right bases and writing really good progress notes.

That freaks a lot of people out.

So a lot of us think our therapy notes have to be perfect, and I know many therapists who spend 25-30 minutes on ONE note for ONE client!

If you see ten clients, that’s already FIVE hours a week of writing case notes, and you’re only getting paid for ten hours of work. No one should be doing 50% more work than they’re getting paid for, right? But a lot of therapists agonize over every word in a note.

Usually that agony is really about a lack of knowledge about what needs to be in a progress note.

I’ve also seen people paralyzed with worry over writing the right thing. They’re so concerned that they don’t write the notes at all, which is actually super common if someone is behind in their notes. The idea of writing the wrong thing is so anxiety-provoking that they just don’t write the note at all.

Now we need a solution, though, right?

So I’m also going to share with you the one thing that I’ve seen help therapists overcome both of those issues: Having a community and a push to get those notes done.

>> My challenge to you today is to find that community and that push.

Whether this blog is the push you needed, or you get together with some therapist friends or coworkers to get through your notes, or you join the Meaningful Documentation Academy and take advantage of our WEEKLY Get Notes Done hours and quarterly Get Notes Done days, find an option that works for you.

Accountability and support are key to solving this problem. Leave me a comment below about your biggest block. Take the leap of putting that out there into the world right here, where there’s no judgment, ever.

Progress Notes and Online Text Therapy Platforms: Doing It Right

These days therapy isn’t necessarily hour-long sessions with a client in your office.

That’s SO 2014. Now we have video therapy and text therapy through apps, which are an amazing tool for you and your clients, and introduce a few new considerations for therapists, particularly around progress notes.

First of all, let’s define ‘text therapy.’ It’s a pretty simple definition but we always want to be clear when we’re talking documentation, right?

Text therapy is providing therapy through any format where texting or online chatting are your main form of communication. This can happen through apps like TalkSpace, BetterHelp, and more. Sometimes you’ll combine video, phone, and texting, and the same considerations would apply to those combos.

Personally I LOVE these formats!

Still, there are a few big points to think through when you’re either considering offering counseling through these platforms or already are offering services through these platforms.

Assessment, support, and information

First, you want to assess your level of risk and figure out how comfortable you are with it. Some people love trying new things and find it easy to think through all the issues and come to a decision. Some have a harder time, and might not love the idea of being dependent on someone else (the app) for record-keeping, etc.

Second, you want to make sure you have a solid support network of other therapists to consult. If you don’t have that network in place, please get working on that before you engage in these new platforms. If you’ve already started, get that network together now.

Third, you’ll need to be aware that you probably won’t have a lot of access to the client information you’re used to seeing. These platforms are great for anonymity, which can be a really awesome tool for your clients. Some clients will feel more comfortable sharing and being honest because they know you have limited info. Some clients may never have considered therapy without the choice to remain anonymous.

Anonymity can be excellent for the therapy process, but it does come with some issues for you to be thinking about:

  1. You want and need basic client information, like name, phone number, and address.
    Why? Because sometimes you get cut-off mid phone call, or the app might stop working, and you’ll need to be able to communicate with your clients if that happens. A client might start exhibiting suicidal ideation or you may realize they’re in danger, and you’ll need an address. Now plenty of your clients will be happy to give you the basics, so just ask them.
    
And then, if needed, keep asking. 

    I’m not saying harass them about it, but as the information is relevant, make a point to ask them again if they’ll share those three things.

  2. Who keeps the records?
    You’ll get to the root of the problem and get the answer you need by simply asking your platform provider what happens in case of a records request. For your own peace of mind and for your clients’ sake, you’ll need to know whose responsibility it is get the clients their records and what is revealed in the process. 
If the app says, ‘Well we don’t have anything to give them,” then you know they aren’t keeping records at all, and you’ll need to keep a full record to CYA. On the other hand, if they say they can hand over entire transcripts of conversations, then you know that what’s being said isn’t completely private, and you need to pass that information on to clients.

And then there’s the notes question.
Where do you write progress notes? How?


Well, you’ll need to know where to access the data you do have on clients. Maybe you’ll keep your own record on the side, or maybe you’ll feel more comfortable keeping a full record. It depends what you have access to through the app.

Either way, keep your notes wherever you have access to the rest of a client’s info. You’ll need access to them in order to protect your clients and yourself, to write reports if a client requests them, etc.

And of course, you need to write notes for EVERY session. If you have specific sessions by chat where you are 100% focused on the client for an hour, write your progress notes as usual after each session.

If you’re texting back and forth all the time, instead you’ll want to do daily or weekly summary notes. So maybe you spend ten minutes talking on Monday, and five on Wednesday, and then a few minutes Thursday, Friday, and Saturday, and you write a weekly progress note.

Maybe you spend lots of time on texting in between video sessions, in which case you’ll need a regular note for the video session and a summary of what’s going on in the texts. This way you’ll be able to refer back to what you’re working through, what techniques you’ve used, and what progress a client is making, even if it’s not happening in a traditional way.

There you have it: If you’re considering starting text therapy, think all of this through ahead of time. If you’re already doing it, make sure the processes you have in place cover everything.

Looking for more information on notes? Check out my Therapy Notes FAQ or the Comprehensive Note Writing Guide for Therapists

And if you want something that covers mental health paperwork in general, sign up for the Private Practice Paperwork Crash Course.

The Things You Carry, Part Two

Guest Post by Christina Kaake

As therapists, here’s a concept you know and love, right?

Well for those of you who have stuff to write, and particularly if you have trouble with writing anxiety, boundaries are your BEST writing friend! Set yourself some keyboard-related boundaries because they give you an incredible edge in finishing what you start and, importantly, making sure you finish strong.

I’m sure some of you are excited about even the concept of a new boundary to set (amiright?) and some of you think this makes no sense at all, so let’s get down to hard rules. Maelisa recently asked a bunch of you who are currently working on writing projects what your writing weaknesses are.

This week I promised to talk more about The Things You Carry—those issues people have mentioned to us that keep them from finishing a writing project and weigh you down.

Writing too much can be an issue (and I would know—word counts are SERIOUS business in journalism), or getting distracted, or simply taking too long. So in our last installment of the Writing Boundaries series, I want to cover those concerns, as well as some general tips.

1001, 1002, 1003, 1004….

First thing first, if you feel like you write too much…well, welcome to the club. You know how I mentioned above that word counts are serious business in journalism? I have agonized over cutting 100 words from a piece, and I have hated it and been sure it’s ruining everything.

Yes, I tend toward the dramatic when I’m stressed.

But the thing is, it doesn’t matter how much I hate it, what matters is that the word count is there for a reason. Sometimes I know the reason—space limits, attention-span limits, consistency—and sometimes I don’t. It doesn’t matter. What matters is I’ve been given a task and, honestly, my writing has been better for it. I’m forced to make sentences tighter and refine ideas. It’s a fantastic exercise, and I’m about to drop it on YOU.

Give yourself a word count.

Catching up on notes? Set a limit and see if you can stick to it—if not, ask yourself why. Are you including unnecessary information, or was the limit unrealistic? I once had an editor tell me to go back and add words because she decided the limit she gave didn’t work for the story. Check the average length of your notes against a colleague, and see where you might be able to trim, or if you’re right on target. If you are, use that average as your limit from now on, unless there’s an anomaly in a session.

Working on a book or scholarly article? Maybe you don’t want to limit yourself, but once you’ve started writing and are ready to re-read a few hours’ work, force yourself to cut 20% of the words and see how it turns out.

Squirrel!

Shiny distractions keep us all from our work.

Sometimes you open a browser window and a suggested article pops up and…two hours later you never actually started your work. Not that I speak from experience. Or you work from home, and kids and spouses interrupt you or make it hard to focus. Maybe you have so many projects that one piece of work is distracting you from another.

If you don’t absolutely need the internet, turn the wifi off on your computer. I know it’s hard. I promise, I’ve been there. But it helps! Put your phone on silent in another room. Without Facebook, Twitter, and those Firefox reading suggestions (again, totally hypothetical), you stand a better chance.

For me, music and headphones help. Headphones serve to focus my mind (although I have no idea why) and some good music in the background just makes me feel like I’m in work mode. Music may not be your thing, but headphones can keep us from noticing what’s going on elsewhere in a crowded office space, coffee shop, or around the house.

Too many projects vying for your attention? Set a specific time to work on each one. Knowing that you have two hours scheduled for project B tomorrow morning can help you stay on project A now. If the two share a deadline, or both have no deadline, then feel free to work on whichever one is inspiring you, but still block out separate time to work on the other. Keep an open document on your computer or a notepad nearby, and write down ideas as they come, but then get right back to what you were doing.

That will keep you from losing any fantastic ideas you have and also allow you to stay on task.

“Cross this line and you’re DEAD”

I had a writing professor who LOVED to say this to us in college. Annoying? YES. Accurate? Yup. Deadlines exist for a reason, and they’re rarely arbitrary. Set yourself a deadline that makes sense for every project you start, and tell yourself over and over that crossing that line is NOT acceptable. I know it’s tempting to ignore self-imposed deadlines, but honoring your deadlines means respecting your own time as a professional.

Keep that in mind, create deadlines, and make a practice of sticking to them.

A final note…

Some people just aren’t writers, and that’s okay! I would be remiss if I didn’t mention that there are lots of excellent professionals who can help you. Consider working with a ghost-writer if you have too much writing to do or your skills aren’t up to scratch. We’re very discreet :)

If all you need is a little polish, you can hire a copywriter to check your work for consistent tone, voice, grammar, etc. If you want to do the writing yourself and have confidence in your skills but need some help with structure, consistency, or staying on track, hire a writing coach.

In all of these cases you can try someone’s services before committing to a long-term contract (although you absolutely must pay them for their time—imagine if your clients asked for a free month of sessions to make sure you’re a good fit). If a ghostwriter sends you a chapter you don’t like, or a coach just isn’t getting your style, move on.

Give yourself the freedom to ask for professional help.

Once again I’ll ask you to consider your own profession: your clients need tools, or they need a helping hand using the tools they already have, or maybe they’re overwhelmed and just need someone to shoulder some of the burden. Just as you wouldn’t want clients judging themselves for needing help, or wanting help, and you would be aghast at someone else judging them, you should never judge yourself if you want or need help with the writing tasks you’ve set yourself. I promise you, professional writers won’t judge you, they’ll just step in where needed and give you a hand, and they’ll be happy to step back out again if you feel like you don’t need them anymore.

This is the official end of the series on instituting boundaries in your writing, but if you have a concern that hasn’t been addressed, never fear! We’re always around, so comment here or send us an email and we’ll get back to you with the perfect boundary.

Go! WRITE!

The Edit Remix

Guest Post by Christina Kaake

Boundaries!

As therapists, here’s a concept you know and love, right?

Well for those of you who have stuff to write, and particularly if you have trouble with writing anxiety, boundaries are your BEST writing friend! Set yourself some keyboard-related boundaries because they give you an incredible edge in finishing what you start and, importantly, making sure you finish strong.

I’m sure some of you are excited about even the concept of a new boundary to set (amiright?) and some of you think this makes no sense at all, so let’s get down to hard rules. Maelisa recently asked a bunch of you who are currently working on writing projects and your writing weaknesses.

We’ve already covered getting your writing started and some common concerns, so this week we’re taking time to talk about the things that ails us most:

The absolute most common issue was over-editing yourselves.

Oh that age-old editing problem. You just can’t stop yourself from tweaking one more word, from checking your comma usage a fourth time, from re-reading it again even though you meant to finish it yesterday.

I'm guessing as therapists most of you fall into one of two categories: either you are writing for your own website/audience and publishing your posts yourself, or you have a chance to send work to an editor (if you're writing for someone else's site, publishing a book, etc.). In either case, you’re worrying more than necessary.

The audience for your websites/blogs/notes (ahem) is less interested in your grammatical prowess than your content. Sure, you might get the odd reader annoyed with comma placement or mentally correcting who's to whose. But those people will have forgotten your editing faux pas within minutes. Seriously! What sticks with us (yes, I’m one of them) is errors in major publications like the New York Times, and even then we know an editor let it slip because they were overworked.

As a professional writer and reader, I have never stopped reading a blog or other interesting content because of editing issues. But your flawlessly-written piece with no punctuation errors and the perfectly-constructed sentences? Those tend to be so over-written as to lose focus, interest, and readability. Remind yourself that the point of your writing is to tell a story, and keep that front and center as you read and edit.

If you're really concerned, use a free online grammar checker. Truth bomb—Even those of us who get paid to write for other people do it sometimes. In fact, I know freelancers who use one for every piece, because the more you re-read something, the less likely you are to catch errors.

For those lucky writers sending their work to someone else for publishing, you HAVE an editor, and it’s their job to find and fix both stylistic and grammatical problems. Stop worrying—they get paid for this!

Since "stop worrying about it," is rarely actionable advice, your best bet is to start by setting yourself an *absolute* limit, and sticking to it. Allow yourself three drafts/edits of a piece of writing, and then STOP. No more. When you get to a 4th read-through, you are no longer editing for clarity or consistency. You are 100% missing any actual problems (science backs me up on this--your brain fills in the right letters and words when you know what SHOULD be there) and simply re-writing. In general I've found that when someone re-writes several times, they either add or remove so much that they lose their original point.

In the end, if you edit too much, you are not producing usable material (if for no other reason than you *aren't using* it). Set yourself a limit, and force yourself to stick to it. Hit the publish button and accept the tiny frisson of anxiety we writers still feel every single time. And if you're still worried, know that I once re-read a resumé I sent in for a writing job and was horrified by the mistakes I found in matching tenses. The editor who wanted to hire me? He didn't care.

Next week, we’ll get back to more of The Things You Carry, so if you have a specific concern you’d like addressed, leave it in the comments!

The Things You Carry

Guest Post by Christina Kaake

Boundaries!

As therapists, here’s a concept you know and love, right?

Well for those of you who have stuff to write, and particularly if you have trouble with writing anxiety, boundaries are your BEST writing friend! Set yourself some keyboard-related boundaries because they give you an incredible edge in finishing what you start and, importantly, making sure you finish strong.

I’m sure some of you are excited about even the concept of a new boundary to set (amiright?) and some of you think this makes no sense at all, so let’s get down to hard rules. Maelisa recently asked a bunch of you who are currently working on writing projects what your writing weaknesses are.

Concerns that came up a lot were overthinking what you write and/or writing too much.

We also heard from people who are too personal or too vague, and from a few of you who love exclamation points (ahem, Maelisa). Over the next few weeks, we’re going to address all of those problems, and every single one has — you guessed it — a corresponding boundary!

Last week we talked about getting your writing off the ground. This week we’re addressing some of your specific concerns, what I’m calling The Things You Carry.

Punctuation

Some of you overuse exclamation points! You use them a lot!! They are your BEST!!! FRIENDS!!!! This one is simple. You now have a one-exclamation-point-per-piece rule. What constitutes a piece? A blog post, a short article, or a chapter in a book. In a longer article, limit yourself to one per section of your article, and *try* not to use them in consecutive sections. Let your passion and excitement show through your work, not through your punctuation.

When you’re just…vague.

We’ve all been there. You know you have a great point to make, but you can’t quite get to it. You’ve been writing in circles, coming close without ever getting into the details. The easiest way to go from vague to specific is by giving an example.

Here’s an example (see what I did there?): If you were a designer giving someone a color scheme, you wouldn’t say, “I recommend maybe a few shades in warm tones and one or two cooler options, along with one surprising neutral.” You’d say, “What I’m thinking is coral, mustard, and olive with navy accents, using a pale pink for your neutral.”

Do the same in your writing. There’s a reason we use the adage, “show, don’t tell.” It’s because it works! So if you want to talk about why HIPAA compliance is important, tell me a story about what happens when I’m not compliant. Worried about confidentiality? Make up a phony client and give them a real problem. And if you once overcame exactly the issue you’re talking about, give me an outline of how you did it and what your life/business looked like after you did. That leads me right into how personal is “too” personal.

Or when you go way beyond vague

Maelisa addressed this with some great encouragement. When you get personal, you connect with your readers in a special way, and they will absolutely love it. For some of us though, the boundaries between personal and professional are sacrosanct.

That’s okay! You can be personal and set yourself a few limits to keep your privacy intact. First, run your story past a trusted colleague, because they’ll have a better sense than you will of how personal it really is. When we have lived something, and then we write it, we feel vulnerable and exposed in ways we might not really be exposed, because we know all the background. Fresh eyes and ears will help.

Second, if you can remove specific details without hurting the story arc, do it. I know that tapping into anger was helpful to me in my divorce, and I use some quirky details to engage readers, like how I blistered my fingers mopping the floor while thinking about our marriage. I can refer to the imaginary conversations I had with my ex about exactly which actions hurt me, and how, and why I was angry. I spent hours having that imaginary conversation, racking up the charges I had been minimizing for years in an attempt to make my marriage work. I got MAD. That anger helped me reclaim my story by focusing on how my decisions made me feel strong and in control.

In that story I haven’t referred to the specific ways I was hurting, but I’ve still made my point. The details about blistering my hands (true!), and referring to the imaginary conversation, which so many people engage in, make the story personal and give it staying power without making me feel vulnerable.

Too vague and too personal are opposite sides of the same coin, but I promise you that with practice, it gets easier, and honestly most of us are our own worst critics (another one of those very true clichés). So get another set of eyes, and then listen to their evaluation.

I know some of you are saying, but what about my issue? Never fear! We’ll address more of the Things You Carry next week!

Boundaries, Writers! (A four-part series)

Guest Post by Christina Kaake

As therapists, here’s a concept you know and love, right?

Well for those of you who have stuff to write, and particularly if you have trouble with writing anxiety, boundaries are your BEST writing friend! Set yourself some keyboard-related boundaries because they give you an incredible edge in finishing what you start and, importantly, making sure you finish strong.

I’m sure some of you are excited about even the concept of a new boundary to set (amiright?) and some of you think this makes no sense at all, so let’s get down to hard rules. Maelisa recently asked a bunch of you who are currently working on writing projects what your writing weaknesses are.

Concerns that came up a lot were overthinking what you write and/or writing too much.

We also heard from people who are too personal or too vague, and from a few of you who love exclamation points (ahem, Maelisa). Over the next few weeks, we’re going to address all of those problems, and every single one has — you guessed it — a corresponding boundary!

Get the Party Started—Part One

I’ve been there: The blank computer screen and the 1001 excuses not to focus on it. I think every writer (or college student) has been there. There’s always something else you could be doing, another project that needs your attention, and the nagging self-doubt that always seems to win those internal arguments.

If you have trouble starting there are boundaries and tips to get you over the hump.

A few of the boundaries are simple, so we’ll start with those.

Make It Happen

Set yourself a schedule. Whether you write daily, weekly, or monthly, or you tackle your projects for one hour or eight, successful professional writers know that you need to treat writing like any other job.

Create your schedule and stick to it just like you ask your clients to do.

You probably won’t charge yourself for a skipped appointment with your laptop, but you should remember that a note left unfinished could rear its ugly head with real-life consequences and web copy left unpublished results every day in missed sales and missed income.

Once you’ve got your schedule, make sure you set a specific goal every time you sit down to write.

I’m not talking goals like, “I will start my book today,” or “I will catch up on notes.” You want to sit down with a plan for a topic you’ll deal with or a number of words you’ll write. For example, “Today I will explain how I’ve used a reward system to get through a task that was difficult for me to stay focused on and finish in a timely manner.”

If that’s not enough to get you started, try some writer-tested, writer-approved techniques for breaking free of writer’s block.

Free writing and writing prompts are two techniques that work just as well for your professional work as they do for fiction writing. Using the example from above, if I know I want to explain how my reward system has worked but I’m still having trouble getting into it, I can free write about goals, rewards, and do a little journaling about the experience I want to relay to you.

Even if you go off track, allow yourself the freedom to do that.

Stick to your boundaries by setting a timer for your free writing exercise. When the timer goes off re-read what you’ve got and start pulling the important points out to expand on them.

If prompts are more your style, write some for yourself. Think of the question you get asked most often, and how you answer it or why it’s so difficult to answer for people.

What research is needed to tailor the answer to a person? Or what is frustrating about the question? Once you get stuck into answering those prompts, you may just find yourself with a blog post ready for editing. If you’re writing notes, try prompting yourself by asking what stuck out to you most from the session, and why.

If you’re still having trouble, try combining your new boundaries with a little excitement.

Treat Yo’self

How we all feel about this 21st century advice is probably a topic with enough oomph for its own entire set of blog posts. But I’m not advising that you go out and buy a new video game or purse, or have a night out at an expensive restaurant every time you write.

I’m talking about a small system of goals and rewards.

A few years ago I was regularly reviewing books, which in case you’re wondering, is a compulsive reader’s dream. Unless, of course, the book is badly written. The thing about journalism is that it includes a deadline for every project, which means having a hard time getting started is a Very Bad Problem.

One day, as I was trying to convince myself to read a particularly onerous book because the review was due the next day, I came up with a system. I knew what I really wanted to do was binge-watch my favorite show on Netflix. So I made a deal with myself that I could watch one episode for every two chapters I read.

Having that small reward to look forward to was truly a weight off my shoulders.

I could commit to two chapters at a time and in fact, most of the time I could get through four or five before stopping. I was able to finish the book on time, and the review, and I also gave myself permission to rest and relax.

If your writing project fills you with dread, give yourself permission to chill when you reach small goals.

Make sure they’re treats you really will be able to enjoy, and that will give you a true break from your work. If you’re a social media junkie, give yourself 15 minutes to zone out on Insta once you finish five notes. If you’ve got a new murder mystery on the bookshelf, let yourself read two chapters for every 500 words you write. If you love to bake, try out a bread recipe that requires resting and kneading, and work in between.

Regardless of what you choose, the excitement of getting that time to do something you love will keep you motivated and give you new energy to re-focus when you come back to your writing.

What tips and tricks have you used to get yourself on track?

If you need some help making your writing projects happen, consider joining the Therapist Writer’s Support Group. You got an email about it last week if you’re on the QA Prep mailing list and if you’re not already on the list, you can sign up here!

You can also check out some of Maelisa’s past blogs about writing notes here and here.

Documenting Text Messages and Emails

“Do I need to copy and paste all emails from clients into their file?”

“How do I document or save text messages with clients?”

These are concerns that usually come up for mental health therapists after they start seeing clients, and after they’ve reviewed policies and procedures with them. It’s okay though, even if your client starts texting you out of the blue and you had no policy around this, you have plenty of options for documenting this conversation… easily and simply.

Let’s review some tips for documenting text messages and emails with your counseling clients:

Think of texts and emails like voicemail.

Remember when all you did was talk on the phone? Life was so much simpler then… in some ways.

The problem is that we often over-complicate things when they are new, and texting or emailing with clients is still relatively new in the world of mental health.

But when you think about it, texts and emails are commonly replacing communication that would have happened over the phone 20 years ago… so a good question to ask yourself is, “What would I do if this were a voicemail?”

You’d likely write a brief note about the interaction. For example, you might write something like:

“Client left voicemail cancelling session due to being sick. I called her back and she will attend next session on xx/yy/zz.”

That’s it! Easy!!

Same thing with a text or email communicating the same type of information. Simply write a brief note in the file so you remember what happened and it’s documented for good.

Summarize, summarize, summarize

I really don’t believe it’s necessary to copy and paste most emails or text messages with clients. The key is to make sure you do have the communication documented in some way, and the easiest way to do this is to summarize in a brief note, like the example above.

Don’t overwhelm yourself!

Tracking and copying all this information may be unrealistic but it doesn’t mean you’re being unethical or not able to document the important aspect of the communication.

And if you prefer to have ALL the back and forth communication with your clients, there are actually some cool apps available that will save this information for you. They offer a secure way to text with clients and the ability to print out or review any text messages.

The added benefit of email and text communication with your therapy clients is that, when needed, you actually can copy and paste the entire communication.

While I don’t recommend doing this every time, it can be very helpful when ethical dilemmas arise or when there is confusion about the communication.

So, in my opinion, these types of communication can actually be more useful than voicemails! It is unlikely you’d want to save a full voicemail from a client, but copying and pasting a long email into your EHR takes about 30 seconds… and gives you a secure way to save potentially important communication.

Let us know in the comments below:

Do you save all your emails or text messages with clients? Do you use an app to communicate with clients and save all the data?

Remember, there’s no right or wrong answer here and we can all help one another by sharing.

Therapy Interventions Cheat Sheet for Case Notes

You may have heard me mention that I don’t usually recommend treatment planners for notes and other documentation.

That’s because these planners rarely save time. In fact, I hear from many counselors who tell me they actually end up taking more time and definitely create more confusion.

These planners also don’t help you personalize your progress notes. That’s why I created this video!

In this video I not only walk you through the benefits of creating your own cheat sheet, but I’m actually sharing 10 therapy interventions that you can steal and add to your cheat sheet right away.

Not into watching a video?

Well, you’ll miss out on the examples of how to implement a lot of these, but I’m listing them here for your convenience!

These are 10 therapy interventions that pretty much ANY mental health counselor needs to have in their case note writing arsenal:

  1. Assessed

  2. Challenged

  3. Demonstrated

  4. Evaluated

  5. Explored

  6. Identified

  7. Labeled

  8. Normalized

  9. Reflected

  10. Processed

Want even MORE interventions for your case notes?

Click below to download the Therapy Interventions Cheat Sheet and start saving time on writing case notes without losing quality.

Process Notes: What You MUST Know

Maybe you’ve heard some of these terms and are confused about how they are different (or the same!)…

  • Process notes

  • Progress notes

  • Psychotherapy notes

  • Case notes

  • Clinical notes

What do all these terms mean?!

Fear not, amazing therapist, I am clearing this up in the video below!

And in case you’re not into videos, here’s a snap shot of what I cover:

  1. “Psychotherapy notes” and “process notes” are the same thing, we all just tend to use different terms. The term “psychotherapy notes” was created specifically for HIPAA so this impacts how we use this term.

  2. Process notes are totally optional! Yup, there is no requirement to write them, so it’s totally up to you.

  3. Process notes don’t even have to be legible. You can draw, use shorthand and abbreviations. In short, you can do what you want since they are just for you.

But most importantly, process notes are NOT a place to hide important clinical information that may be needed for treatment.

Your progress notes should always document treatment and should be able to stand alone to tell the story of your client’s journey in therapy.

Now, let us know! Do you use process notes? Why or why not?

How To Catch Up On Notes

One of the most common concerns I hear from therapists is that they are having trouble staying on top of their progress notes.

This is a big concern and the problem can get out of hand very quickly. 

That's why my approach to helping counselors catch up on progress notes consists of two things:

1. Create a sustainable strategy for staying on top of current notes.

2. Create a realistic plan for catching up on older case notes.

Once these two things are mastered, you're good to go! The hard part is getting there...

That's why I recorded the following videos with steps on each strategy.

One caveat: It is tempting to jump to the catch up plan because that may be the immediate need that is causing stress. Don't do this!

It is sooooo important to create a sustainable schedule for yourself first so that we break the cycle of falling behind on progress notes. So, make sure you watch Part 1 and really focus on trying out this strategy for a week or two before you jump to Part 2.

How To Catch Up On Progress Notes (Part 1)

Create a sustainable schedule for ongoing case notes

 

How To Catch Up On Progress Notes (Part 2)

Create your catch up plan for your case notes

Do you want extra support to get some progress notes done ASAP?

Click here to sign up for the Summer Paperwork Blitz!

What is the BEST Case Note Template?

There are many different progress note templates to choose from and I often find that people are using a psychotherapy note template they don't like... so what do I recommend? Well, that depends on you!

The Bad News: The best case note template will vary with each clinician.

The Good News: The best case note template will vary with each clinician... so you can make some quick changes right now that will improve your progress notes!

Watch the video below or read the summary underneath for some details on how you can do this today.

Here are some quick things to consider before adjusting your progress note template:

  1. What sections of my case note do I like?

  2. What template sections seem insufficient?

  3. What do I write that doesn't seem to fit in one of my current case note template sections?

Then look at ways you can easily make adjustments to just these sections. You don't need to change the whole case note template! Add a section, take a section away, etc. Do what works for you.

Next, add checkboxes... but do it carefully and thoughtfully.

For the psychotherapy interventions section:

Don't go off someone else's list of therapy interventions. Sure, you might use a list to gather ideas but don't include every possible therapeutic intervention, because you won’t use them all regularly. If you're ignoring something all the time it is just getting in your way- delete it and move on!

For your client's response section:

Particularly if you work with similar types of clients, you will often have similar client responses in progress notes over time. Again, if these come up often then create checkboxes. If not, you can ignore this part... do what works for you ;) 

For the plan section:

You likely have common recommendations for your clients so why not create checkboxes that will make your life (and your progress notes) easier? You can always leave blank spaces to provide more detail on things like dates or specific recommendations.

Want to see some examples?

Click here to sign up for the FREE Private Practice Paperwork Crash Course and you'll get immediate access to video trainings, case note templates and progress note examples.

Quick Clinical Case Notes (Collaborative Documentation Q&A)

Recently I've been getting a lot of questions about a somewhat controversial topic- collaborative documentation.  While I don't think everyone should use this strategy, I definitely think it's worth considering. 

Collaborative documentation (sometimes called concurrent documentation) can actually look very different for different therapists!

In this video I review four ways you can incorporate this strategy in your counseling practice right now:

  • Writing notes with clients in session

  • Writing part of the note with clients during session

  • Sharing notes with clients after they are written

  • Having clients complete intake paperwork before the initial session

I also go through some of the benefits and potential drawbacks of this technique:

  • Less time writing notes (the most obvious benefit!)

  • Increased communication and connection with your clients

  • Reduction of errors in documentation

  • Better engagement of "resistant" clients

If you’d like to submit a question for me to answer on a future YouTube Live Q&A, then click here.

>> Subscribe to my YouTube channel and click the bell for notifications so you don’t miss the next Live Q&A! 

I'm on every Monday at 12pm Pacific Time.

If you’re still looking for help with your documentation, click here to check out the FREE Private Practice Paperwork Crash Course

Do Therapists Really Get Disciplined for Failing to Take Notes?

One of the biggest concerns I hear from counselors about their documentation is whether or not their notes will be read by someone else. Usually they are most concerned by a potential court case Their concern is that the notes will somehow harm their client in this case.

Click here to read about whether or not I think limiting your note content can help you or your clients with court cases.

Secondly, the concern is about others reading their notes and that they will be deemed an incompetent or negligent clinician when the notes are revealed. 

Why are so many therapists worried about their notes somehow revealing poor practices? 

I find that the lack of clarity about what to write in therapy notes contributes to a LOT of worry. That worry builds when counselors seek out information about how to write progress notes and they find a myriad of conflicting information from seemingly reliable sources. 

The worry grows exponentially when that same counselor falls behind in their notes and needs to catch up on paperwork

Then you add to that a horror story of another counselor being put on probation or losing a contract due to poor note writing and this becomes a real concern!

But is it true that psychotherapists get disciplined for poor record keeping? Does this really happen?

Yes!

I find this commonly happens when some other catalyst creates a client complaint or Board investigation.

When the Board begins to investigate and requests records, they often find two additional problems (other than the original complaint):

  1. The clinician failed to obtain proper informed consent.

  2. The clinician failed to maintain adequate records.

Keep in mind that these common scenarios are regardless of whether or not the therapist is actually found to be at fault regarding the original complaint. 

So, let's dive in to each of these two scenarios and see how to avoid these common issues...

The clinician failed to obtain proper informed consent.

1) This often occurs when therapists are providing services to children and adolescents. The therapist may fail to inform the parents when it is required or may fail to obtain consent from the correct party (or both parties, if required). Similarly, this can also happen when a dependent adult is being treated.

2) I've also seen cases of this when a psychologist failed to obtain proper consent for psychological testing or did not adequately document reviewing the differences between a testing and a therapeutic counseling relationship. 

3) There are also scenarios where the therapist does not actually review the informed consent process at the beginning of therapy. Instead, they simply make sure forms are signed and don't review any policies or procedures, potential limits to confidentiality, or describe the therapeutic process.

When counselors are too lax about the intake process and jump right in to the therapy process they set themselves and their clients up for a potential disaster and significant harm to therapeutic rapport.   

4) Lastly, the counselor may simply fail to document that they obtained consent for treatment. I always recommend you document in an intake note that you reviewed necessary policies, potential limits to confidentiality and obtained consent for treatment.

The clinician failed to maintain adequate records.

1) One common problem here is that the therapist simply has incomplete records. They may be missing case notes, informed consent documents or other necessary paperwork, such as releases of information.

2) Another common problem is that the therapist has case notes but no other supporting documentation, such as a treatment plan or intake paperwork.

3) Lastly, the issue might be around quality of documentation. For example, the counselor only includes such brief information in their case notes that the Board cannot adequately determine if their actions are justified. Or the counselor may fail to document things like important phone calls or missed appointments that corroborate their side of the story. 

>> It's important to note here that experienced clinicians appear to be more at risk in these areas. I found very few examples of newer therapists being disciplined for these concerns. 

What can you do to avoid these potential problems?

Two ongoing things are critical for every licensed psychotherapist in every discipline, state and country:

So, just reading this blog post you are already on the right track! You're making ongoing learning a priority for your career. 

And despite the fact that you may hear different opinions about documentation practices, regularly discussing these practices with other clinicians, along with educating yourself on best practices, will help you gain the critical thinking needed to decide for yourself what you will do in your practice. 

If you're looking for a community of other therapists with whom you can consult, as well as a place to obtain continuing education credits and learn about individualized documentation techniques, then click here check out the Meaningful Documentation Academy

The Academy incorporates community and education to make sure you are prepared and confident about all things documentation.

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.

We keep your information secure via our Privacy Policy.

Productivity Hack for Writing Case Notes

I've got a quick tip for you that can dramatically improve your productivity when writing case notes and catching up on paperwork!

In this video I share with you the Pomodoro Technique, a popular time management strategy for getting tasks done.

The key to the Pomodoro Technique is taking breaks! Do NOT skip this part and when you're trying it out make sure you stick to the schedule. 

This is one of the strategies we use for the weekly Get Notes Done Hour in the Meaningful Documentation Academy, as well as our quarterly Get Notes Done Days... and people are really liking it!

Let me know how this strategy works for you in the comments below.

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 progress note?

I've got one for you! Check out this sample intake progress 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 intake progress 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 (and especially, your intake assessment process) as much as possible. 

If you have questions about substance abuse, past treatment, relationships, and suicidal ideation in your assessment form, then why do you need to write these things over again in your intake progress 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 notes checklist you can download to create your own intake note template or to use as a reminder when writing your intake progress 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.

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Should I Use a Treatment Planner for My Notes?

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.

Therapy Notes: Your FAQ's Answered

>> 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 with me about their progress notes. 

I've been collecting a database of questions I commonly receive about progress notes and figured it's about time I focused on answering some of these!

There’s a lot of information in this post, so here is an outline of everything below:

  1. Writing Progress Notes Late (weeks or months after a session)

    1. How late can I write progress notes if I’m behind?

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

  2. How Much To Include In Progress Notes

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

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

  3. Worries About Insurance Audits of Therapy Notes

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

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

  4. HIPAA & Progress Notes

    1. What are psychotherapy notes based on HIPAA?

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

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: 

1.Writing Progress Notes Late (weeks or months after a session)

"How late can I write progress 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 progress 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, here is a brief example progress note...

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. 

 

2. How Much To Include In Progress Notes

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

My short answer is no, I do NOT recommend writing two sets of notes! That’s the opposite of simplifying things. However, I get it because I have a horrible memory due to my ADHD and so I have some other recommendations to improve your case and make them easier to write.

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.

Another recommendation is to use my favorite progress notes template so you have a combination of checkboxes AND written data that personalizes the session. This way you can remember what happened, have a complete case note, AND reduce the amount of time you’re spending writing progress 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.

>> It's okay to have good, 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. 

 

3. Worries About Insurance Audits of Counseling Notes

"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 who use their insurance 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 insurance requirements for writing therapy notes, 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 case 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 and your client is getting better then it can appear your client no longer needs services.

>> Insurance is usually 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.

Ask yourself these questions when writing counseling notes for clients who use their insurance:

  • How is ongoing therapy keeping your client from deteriorating, or from needing more intensive treatment?

  • How is therapy 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 thereof) that your client is making, as well as their ongoing need. 

Personally, I 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 problem 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. 

 

4. HIPAA & Psychotherapy Notes

"What are psychotherapy notes based on HIPAA?"

This is a BIG topic and for a more complete answer, I recommend checking out this post on what you MUST know about process notes. 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 or 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 all therapists 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 myself. 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 case 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. 

 

Want to see some actual examples of progress notes?

Click below to join the Private Practice Paperwork Crash Course and you’ll get immediate access to a FREE mini documentation training, complete with progress note examples and a treatment plan template.