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!

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.

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.

Review of Notes and Electronic Health Records for Therapists

It's about time I did a review of some Electronic Health Records (EHRs). I get questions ALL THE TIME from therapists who want to know...

  • What EHR do you recommend?

  • What is your favorite EHR for notes?

  • How do you set up paperwork inside your EHR?

Today, I am answering those questions by providing an overview of eight different EHRs. There are many more EHRs available and I simply haven't been able to check them all out. However, all of these below are ones that I have either tested and played around with or received a virtual tour from staff at the EHR (super thankful for all their time answering my questions and showing me around!). 

Important note before you dig in:

I am not personally endorsing any of these EHRs for your practice. I strongly believe that with all things documentation, you need to use what works best for you and that will often be different from what works best for other people (including me). So, please do use this as a resource to get an idea of what you might like and then try it out for yourself.

Although I do receive an affiliate commission for some of them, I am 100% honest about what I like and don't like about each EHR and let the EHRs know that up front, as well. I know you certainly don't want me holding back ;) 

To be as fair as possible, my reviews of EHRs for therapists are listed in alphabetical order:

Counsol

Okay, let's get this out of the way- yes, this is the EHR I am currently using. Why did I choose it? Because it offers integrated video sessions for online counseling and because it offers a client journaling feature, along with all the other typical EHR goodies (billing, scheduling, notes, text or email reminders, client portal, etc.). I will be honest though, and say that I haven't used these features nearly as much as I originally anticipated.

Now, let's get into the specifics here:

Counsol does not have a clean, modern look like some other EHRs, but the function is the same. For notes, there is one template with mutliple sections. You can choose which sections of the note you want to include or hide, although the note itself is not super customizable (which is a big disappointment for me, personally... you know, since I'm all about making documentation meaningful and personalized!).

The notes provide checkboxes for interventions and the assessment section, as well as free text fields to add other notes, and provides a WHODAS score and diagnosis dropdown list so you can make sure you're staying on track with symptoms. As I've mentioned before, beware relying on the check boxes, which would be very easy to do here and give you almost no info about what actually happened in the session.

Counsol also allows for the option to have separate internal notes (process notes) or specific free text notes that are shared with the client. I really enjoy this feature since it makes collaborative documentation and ongoing communication with my clients really easy. If I mention a resource in session, such as a book or website, I simply include the link or name in the note and they can look it up any time. 

If you don't want to share notes with your clients, this is an optional feature, so don't let that part freak you out.

One big caveat for those of you who tend to be disorganized or fall behind in notes: Counsol does not remind you if a note is not complete. There is no way to tell if a note has been started or finished without actually going in to the client record. So, if you're the type who needs those reminders, you may want to check something else out.

Another option for personalized notes or treatment plans is to add these as a form within the system and write that way, although it's a bit more cumbersome. I do love the form creation within the system so clients can easily sign or complete paperwork ahead of time. And you are also assigned a customer service representative who will help with any set up or questions. No need for emailing a generic info@ email.

ICAN Notes

This may possibly be the most robust EHR available for mental health professionals. It has many cool features that could be conceived as really cool, but possibly overwhelming... depends on your definition of both those words ;)

Within all sections of the EHR there are “shrubs” to prompt you for writing things more easily. These are shortcuts that you can create on your own for phrases or templates you regularly use for assessments, notes, etc. There are also pre-created shrubs if you want to go with what's already there. These seem really useful for prompting counselors on things like what to ask for justification of a specific diagnoses, adding in severity, complexity, writing an MSE, etc.

There are also specific phrases and templates for group and play therapy, which many EHRs overlook. And if you treat substance abuse, there are tons of pre-created phrases and templates related to this, as well. 

There is also a client portal with option to email inside the EHR, show notes to clients, have clients sign paperwork in the system ahead of time, and you can send forms directly from within the system. You can also use a custom form builder and there is the ability for clients to add historical information for assessments prior to coming in.

Yes, this is a robust and potentially overwhelming EHR. However, they do offer unlimited training sessions that are one-on-one, and this is included with pricing. Another feature you won't get from many EHRs. 

Mentegram

Mentegram is a fairly new EHR and is very receptive to customer feedback. I've been impressed by the speed with which they're able to make adjustments to their system and add requested features. This could be a huge benefit to joining in the earlier stages.

This EHR offers the ability to do video sessions within the EHR, which is always a nice feature for clients to have a "one stop shop." There are multiple notes templates (DAP, GIRP, PAIP, SOAP... hm, sound familiar??) as well as a free text note available for anything else you want to write.  

You are able to upload and use any forms, and do scheduling and billing. One really cool and unique feature of Mentegram is the ability to integrate client data from outcome measures or progress based on what clients enter in the client app. Yes, that means you can assign your clients a quick questionnaire to do and the information is uploaded without anyone needing to do anything further!

So, you could assign a client to track their sleep every day or use it to have clients check in about their mood once a week, etc. Other EHRs usually charge extra for anything like this and I really appreciate what Mentegram is doing here. 

PsychScribe

This is an all in one app that you can easily use on your phone or tablet. Yes, this EHR is only offered as an app so it is not currently available on your desktop computer.

PsychScribe has a great layout and simple design, making it easy to follow and use. There are lots of note templates, although none are customizable and there is no option for only a free text note. So, I could see that being needed every once in a while.

If you like a lot of prompts and don't want to think too much about what to include in notes, this might be the EHR for you. The notes can appear a bit long but really would not take long to complete since it is a lot of checkboxes and prompting. It also has specific options for play and sand tray therapy, with the ability to directly upload a picture to the note.

PsychScribe is NOT for you if you bill insurance electronically, unless you want a completely separate system. It is also does not offer the option to charge credit cards, so I recommend using Ivy Pay instead (also an app that's really easy to use).

There is no client portal or ability to upload forms, so you would need to do forms on paper, then take a picture to scan into the client's file on the app and then shred the paper (yes, you can shred paper after you upload it electronically).

Simple Practice

This is a very popular and affordable EHR option that also continues to improve and add features based upon customer feedback. SimplePractice has a beautiful layout that is similar to the clean look of Apple products. It offers a client portal, the ability to upload forms, have clients complete forms ahead of time, online scheduling and messaging, etc.

For notes specifically, you can use their DAP template or create own template. However, you do need to sign up using the mid priced tier if you want the ability to create your own notes template (and you know I always want this ability!). There is also a separate section available for those of you who write process notes, so you can feel they are separated from the main record.

For those of you who need it, SimplePractice does prompt you to write your notes and will keep count of how many notes are pending. However, remember to LOCK your notes after you've completed them. Locking your notes is the same as signing them in the electronic world. Unlocked notes are essentially unsigned notes. 

Most therapists who use SimplePractice love it and recommend it to others. They offer weekly trainings and office hours to ask questions and are very receptive to adding new features that are commonly requested. Plus, they had me speak at their live event last year and then write a guest blog post so I think they're awesome for that ;) 

You can click here to check out my guest blog post on How to Use an EHR Like a Pro.

TheraNest

Very similar to the EHR above, TheraNest offers a simple, clean layout that is easy on the eyes and easy to navigate. There is a client portal, forms uploading, scheduling, and billing. They also offer easy pricing if you want to add other clinicians, charging by number of clients rather than number of clinicians.

Their notes are also simple and allow for customization. They do offer a treatment planner but this wasn't my favorite feature since it seemed overly complicated.  But my personal pet peeve is the whole Goal-Objective-Intervention thing, so that may just be me. FYI- I think you can make goal and objective the same thing, but I'll save that for another treatment planning blog post ;) 

TherapyNotes

Another robust EHR that offers a lot of templates and pre-formatted options is TherapyNotes. One cool features is that notes have the PQRS built in for those who bill Medicare. 

However, you are not able to customize notes or hide features within the pre-created templates and there is a LOT of information in those notes! Some information is required so you have to write something whether you value that field or not. Other sections in the pre-created templates are not required so you could skip them.

However, I never like using this as an option since things get messy when trying to remember what section you completed last time.To avoid this, you are able to rename templates and there are a few different options so you could create your own from a couple of the free text field options. One benefit of using this type of system is learning what you commonly write over and over and then copying and pasting some of those common phrases to save yourself time.

Justin from The Testing Psychologist likes this EHR for easy use with notes for psychological testing. The note adds up time for each test completed, has drop downs for different tests and prompts for other things like to whom the report was released and if feedback was given. Definitely a unique feature and very cool for testing peeps! 

This EHR also pulls in information from the treatment plan and you can use the history feature for previous similar entries to save yourself time typing the same thing over and again (although, beware writing the same notes too often!).

If you do intake assessments in person, this uses a note to complete the intake. The intake note asks for diagnosis justification after assigning the diagnosis. It would be great for people who want reminders in their to do list and reminders for what to write in each section but beware using too many drop downs and losing a more personalized description of what's really going on in your sessions.

Therapy Partner

As far as group practices go, this may be the best option I've seen. Therapy Partner was founded by a therapist with a group practice so a lot of the intuitive and nuanced things about having multiple locations and/or multiple clinicians are integrated with this EHR. For example, you can give permissions to different users so that clinicians can view and document for their own clients, but not see clientele at another location. 

Regarding documentation, Therapy Partner meets my standards for customization! They do have a few standard templates to choose from, with various sections and check boxes for things like interventions. These templates also integrate with the current diagnosis listed for a client (if applicable).

However, if you want to use your own template, you can send them a Word document version of your personalized template and they'll create it in the system for you! I love this service. 

There is no specific or integrated treatment plan within Therapy Partner, but you would easily be able to give them a Treatment Plan template using the above system and then complete that document for your clients as needed. 

They will be releasing a client portal in late fall/early winter 2017. This is probably the biggest feature currently lacking for Therapy Partner but they seem to have a good sense of customer needs so they have been testing this feature with a few current clinicians and it will be releasing soon.

Getting started with Therapy Partner is pretty easy since they offer a free trial. You can also use the promo code "QA Prep" and get two months free, rather than just the typical 30 days to try it out. They also provide extensive help with set up, walking you through things like integrating your merchant account, adding clients and uploading forms. You also have an assigned customer service representative so you have a specific person to call when you have support needs later on.

WeCounsel

WeCounsel is another EHR that offers the ability to do video sessions with clients inside the EHR and gives you that one stop shop for all things client file, billing, online sessions, etc. 

With WeCounsel you can easily add a free text note or use of their many templates. They have a detailed intake template if you prefer to ask questions of clients in person rather than having them do paperwork ahead of time. I also like the ease of adding an addendum to any note- it shows up nicely underneath the note and is super quick for those circumstances when you realize you've locked a note but forgot to add something important.

It is very easy to read through all the notes on a screen by scrolling down so reviewing the file is simple and won't take you a ton of time. WeCounsel does not allow for creating a new template, so you'd have to choose the free text field and add your own template each time for personalized notes. Personally, the pre-created templates have too much info for me, but if you want something really directive, you are able to use them. Again, to each his/her own!

The overall client file interface does not feel very organized and forms are uploaded to show in a long list, which can become confusing if you do scan and upload a lot of forms rather than doing them within the system. 

That's that!

So, what do you think? Do you use one of these EHRs and have additional things you want to share? Don't see your EHR reviewed and want me to reach out to them for a review?  Let us know in the comments below!

Clinical Supervision and Notes: How to train your clinicians

clinical supervision of notes

By far, the most common thing I hear from clinicians is that they didn't receive any (or sufficient) training in documentation.

This is a topic that is very important to all of you. I know because you tell me, you read this blog, you watch the videos and I consistently hear the same thing again and again in workshops. 

Since many people who are supervisors are the same counselors who never received training in documentation themselves, they often don't know where to start with their supervisees.

That's what this blog post is for!

I'm going to outline some different ways to review documentation and notes with your fellows, interns, practicum students and trainees. You may not use all of them, especially if you're new to this, but I guarantee some of these steps will give you ideas for where to start or how to improve. 

1. Review files and notes every week (or however often you meet).

It can be tempting to spend time in supervision focused on the more "interesting" clinical content or to address the crisis of the week. However, your supervision time should incorporate training on ALL aspects of being a clinician. 

And that includes getting paperwork done and evaluating how effective that paperwork is.

Spend some time looking through a client's file, particularly if it's a client about whom you're already discussing a crisis or clinical issue. Not only will this ensure all the legal ducks are in a row, but going back to earlier stages in treatment can often provide clinical insight now that you've spent some time with this client.

2. Read through an entire file, not just that week's notes.

This one is huge! Working as a Quality Improvement Specialist in a few different agencies, I noticed that I would often pick up on things the supervisor hadn't... even when they were regularly reading and approving weekly notes. 

That's because the supervisor was focused only one note.

Looking at that note alone, it seemed fine. However, when read within the context of the client's full file (as I was reading), certain things stand out.

For example, if something significant had happened in the previous session and that session's note had identified some follow up that would happen, I was looking for that in the next note. If that follow up was missing I picked up on it right away because it made the client's story disjointed. 

However, the supervisor could easily overlook this because they were simply focused on the one note and whether or not that content was coherent and professional. Not a bad thing, but taking a different approach every few weeks will provide a different context.

3. Practice together, especially in the beginning.

Do you remember writing your first case note? I do. I remember that I had a few samples in front of me and while they seemed great, they all of a sudden seemed completely irrelevant to the note I was writing. So I simply dove in and tested the waters to see what would be approved.

Now consider if my first experience writing notes had been with a supportive and experienced clinician guiding me. I would've had a chance to ask questions, compare things, get different ideas for wording, etc. 

I know what you're thinking... notes are boring and no one wants to spend time together writing notes. However, I've found this to be the opposite! 

One of the things people consistently mention about my trainings is that they enjoy seeing examples, watching me write notes, and writing notes together. They even really like getting feedback on the notes they've written.

However, this is something that is often nerve-wracking for people and it's unlikely anyone will ever ask you for it. You must initiate but I promise you that 99% of the time, it will go very well.

So take the time to review paperwork, practice writing things together, and continue to do these periodically throughout your supervision time, not only in the beginning or not only for people who appear to be struggling. 

You will create much more confident clinicians who are able to focus on what matters most- how to best help their clients. 

Now you tell us! What have you found to be helpful when working as a supervisor. What did a supervisor offer you that provided you the confidence and tools you needed to be successful? Let us know in the comments below.

Catching Up On Notes: An Interview with an Honest Therapist

We've ALL gotten behind on notes. Yes, all of us. 

The problem is that we never talk about it. And the more behind you get, the LESS you want to talk about it. But that makes the problem worse, and so things go on and on until you feel overwhelmed.

That's exactly what I'm talking to Dr. Traci Lowenthal about today. Traci got behind in her notes, and was courageous enough to let me interview her about how she's getting caught up and how she plans to avoid this happening again in the future.

Click below to check out the video and share this with your friends! I guarantee you know at least one counselor who is behind in notes right now, but too ashamed to discuss it. 

Wasn't she awesome to share her experience with us?! 

If you're also behind in your notes but not sure how to start getting caught up, or if you need some extra motivation, check out the Paperwork Catch Up Group

This is a group where you get the practical tips as well as the moral support you need to get caught up and stay caught up on notes. 

And if you have your own tips and tricks you'd like to share, leave a comment below! Remember, you're not alone.

Writing Your Client's Journey: Interview with Jo Muirhead

While blog posts are helpful, sometimes you just want to hear what someone else is doing and model things after them! That's what I'm doing with the regular "Writing Your Client's Journey" series and to kick things off I interviewed a very successful group practice owner in Australia, Jo Muirhead

Jo shares some excellent tips on things like streamlining, creating systems and encouraging your motivation to get paperwork done.

You'll notice some sound distortion in just a few spots but it's very brief and there's a ton of great tips so stick with it! And if you've only got a few minutes to check things out, scroll down further for the interview highlights.

My favorite quote from this interview is early on when Jo says about paperwork and systems, "If you can't learn to love it, you've got to respect it because hating it helps nobody."

In the beginning of her practice, she tried to customize her systems and forms to meet each individual client's need but then found out that wasn't working as her practice grew. So, Jo started to create systems for getting all the mundane but necessary stuff DONE.

Creating a system for yourself makes things more simple and easy. Without these in place, you can easily be distracted from the work you really want to do- your clinical work with clients. 

Prepare for growth by having directions for things written down for anyone who may need it later on (e.g. an assistant or a new clinician). This can save you hours of time... Jo and her team set up one system that turned end of month financials from a 10 day task into a two day task!

Specifically, some tips that Jo shared during the interview are: 

  • Set up a checklist for each task

  • Create a centralized place and system for all tasks

  • Teach a child or a partner (or team up with another clinician) how to implement each task to identify holes in the system

  • Schedule everything (especially notes and accounting)

  • Use LastPass to manage all your passwords for every site that requires a password

Important things to focus on streamlining: Intake and discharge

Important things to keep up with regularly: Notes and bookkeeping

Jo also had a great tip for those times when you become overwhelmed by a task. Ask yourself, "What could I have done to make this easy on myself?" Then focus on changing that one habit to improve things in the long-term.

And the big payoff from putting in all this work? Once you have a clear idea of how long it takes you to complete a task, you can decide if it will be worth delegating and, if so, you know what to expect from that person!

Feel free to share in the comments below. What have you found helpful for simplifying paperwork and other administrative tasks? 

Want to learn more about Jo and the coaching services she provides for others? Click here to learn more!

Supervision Notes- Practical Tips for Staying Sane and Organized

Like most notes, supervision notes aren't a big deal until they ARE a big deal... meaning, when you need them! Until then, they sometimes feel pointless and often feel annoying to do.

But you don't have to know much about me to know my schtick- which is making documentation meaningful, simple, even nearly enjoyable!

I'm currently a supervisor for licensed clinicians and I write regular supervision notes so I can remember what's going. Being disciplined about regular notes is key. It's so easy to get behind and then you're playing with fire... because it always seems like that's the time when something "bad" happens.

But it's about more than just writing your notes each week or month... it's about the organization and content, too. So I thought I'd share with you some tips on how to keep organized with your supervision notes so they stay awesome.

Write on a Schedule

While I find it nearly impossible to write a therapy note right after the session, it's not the same for me with supervision notes. I typically do these right after or at least that same day. 

This way I'm never worried. When someone (like HR, yeah, that's happened frequently!) asks me for more info I already have it all laid out for whoever needs it.

This is much easier because my supervision sessions aren't weekly, so I don't feel like I'm constantly writing notes.

Keep it Simple

With supervision notes you can really stick with the bare minimum. I don't really worry about the amount of time we met or where we met. I make sure to include dates and what we discussed. That's it. 

As with everything, there's no black and white rule here. For example, if I had to deal with an employment issue or a crisis I will go into more detail. But if we discussed some standard cases, time off and reviewed a training then that's all I need to write. I save my time typing for the big stuff and then I go into detail.

Be Organized with Files

It took me some time to figure out filing because again, no one teaches you this stuff and there's no specific standard. I do all my notes on the computer and each supervisee has a file. In the file I have a Word document (because this is my day job- at home I use my lovely Mac) that is a running file of supervision notes for the year. 

Each day or meeting is a bullet point. I list the date and then my notes are in sub-bullets. That keeps things very easy to review at a later time as well as organized. 

Did something come up outside of supervision? Did I communicate some important message and want to track when that happened? I list that as a bullet point as well. Easy peasy.

In the file for each supervisee I also keep any pertinent documents. Another thing that's been super useful is to save emails in that folder. For example, perhaps you communicate a new protocol or respond via email to an important situation, save that email in the supervisee's folder. 

This tactic alone has saved me soooo much time! I used to waste a lot of time searching through my inbox folders for things. Another strategy is to simply name a folder in your email inbox for each person you supervise and use that to house all correspondence. This works well if your email traffic is lighter. 

And voila! You've now got an easy way to keep your supervision notes. They're easy to retrieve should you ever need them and easy to review if you ever want to revisit something. 

Leave a comment below with your own tips for writing supervision notes. And if you're still struggling with this whole documentation thing, remember that you can always reach out for individual help from me. Just click here to find out more.

Documenting Consults: Protecting Your Assets

I've had a few therapists ask me recently about how to document a consultation with other psychotherapists. "When do I need to do it?" "What should I include?" "Where does the note go?"

My biggest piece of advice is first, to actually DO it! Many counselors in private practice don't think about how this simple task could save lots of trouble down the line. It doesn't have to be intense or scary (we'll get into that below), but it can be super helpful. 

So, let's get into the What, When, Why and Where of writing a consultation note...

Why

Documenting consultations with other professionals serves a few purposes. Firstly, it proves that you took action to be ethical. Some ethical concern came up and you took the appropriate action. Without documentation, how can your prove that happened? Answer: You can't!

It also helps you clinically. It's impossible to remember everything that goes on with your clients or even with your professional growth. However, if a situation ever comes up a second time, you now have a previous decision documented. You can go back and review without relying on your unfortunately, very fallible memory.

When

I recommend documenting a consultation with a colleague any time the issue is impacting the clinical work or any time it's an ethical concern. You may be part of a regular consultation group and do case presentations. It's not necessary to document each of those instances... unless it meets criteria A or B above.

There are times when ethical dilemmas arise in the moment and you don't have time to consult before you need to take action. These situations are also an excellent opportunity for consultation. Discuss the possible actions you could have taken and get feedback on how to proceed from that point on.

What

Now we're digging in... what in the world do you include?! If you only take away one thing from this post, focus on this word- rationale. The purpose of a consultation is really to document the discussion around the rationale for your decision. 

Include who you talked with and which ethical principles apply. Identify why you needed this consultation. Describe the action you will take and more importantly, the reason for your decision.

Maybe your client shared a significant issue in the last session and it's an area in which you're totally unfamiliar so you consult with a colleague to determine if you need to refer out to a specialist, continue treatment with supervision, or simply review some resources.

Perhaps your client presented you with a pricey gift (let's go with... a Caribbean cruise) and you graciously did NOT accept. Your client seemed miffed and you'd like to consult on how to proceed at this point because you have not had this experience before.

Or maybe your client is requesting ALL of their treatment notes out of the blue. You feel this could be harmful for them and want to be prepared when talking with them about it. You want to make sure you are considering all the laws, ethics and clinical issues at play. 

Note: A distinction is made here with countertransference issues. Often, issues will come up that prompt us to seek our own process and work through our own emotions. Although this does impact your clinical work, the distinction here is that the focus is on you. In some situations you may actually seek consultation as well as your own therapy. 

Where

Now that you've got this excellent consultation note, where the heck does it go? As long as it's specific to the client and a clinical issue with them, put it in their client file. If it's specific to yourself (this would be rare, but you never know!), create a consultation file and put it there. 

Consultation notes = easy... right?! 

Our work is so meaningful and often fun but the unknown, the scary, and (gasp) mistakes are bound to happen. That's where documentation comes in to save the day (cue super hero music). 

Just be your wonderful, ethical self and write about why you're doing what you're doing. Easy peasy. 

Still not totally comfortable with the whole note-writing thing? Check out my free Private Practice Paperwork Crash Course. I talk a lot about notes and even give you some samples to look over.