Using Treatment Planners to Write Counseling Treatment Plans

Treatment Planners, they’re everywhere, right? Treatment and Notes planners are super popular and there are so many options available on Amazon, but are they helpful? Do you need one?

Today I’m going to review:

1. When treatment planners are helpful

2. When they’re not so helpful

3. What to look for in a planner
4. What to do if they aren’t the right choice for you

Watch the video below or keep reading!

First, when are treatment planners useful?

Generally treatment planners are useful when your client has a specific diagnosis, and you treat them according to that diagnosis.

Most treatment planners are based on diagnoses, so if you tend to give a diagnosis as part of therapy and rely heavily on it for your treatment plan, then it makes sense.

All the interventions and client responses in the planner are going to be based on a particular diagnosis. Plus, these treatment planners are ordered alphabetically by diagnosis, making them a good bet if this is how you work.

Which means that second

If your client doesn’t have a diagnosis, or you don’t give diagnoses, then a treatment planner probably won’t fit in well with your work.

We ALWAYS want the treatment plan to be serving us, not the other way around!

If a diagnosis isn’t guiding the focus of your treatment, treatment planners aren’t so helpful. This is the first thing to consider. Don’t buy something that’s going to make your work harder.

Leading us to third:

What should you look for if a treatment planner makes sense for you?

You want a treatment planner that is focused on the interventions you’re providing, the types of clients that you see, and that’s easy to look through.

Consider all these things when choosing a treatment planner:

  • How is the planner you’re considering ordered?

  • What therapy and treatment interventions are provided?

  • What are the therapy interventions based on and are they recent?

  • Does it include interventions that might be based on a particular modality you use (or don’t use)?

And finally, number four:

If treatment planners don’t fit with your practice, you might be feeling down right about now. I know the idea of a treatment planner is awesome. It sounds like the answer to our problems for creating a treatment plan, but often it is not.

But I have GREAT news!

I have a FREE treatment plan template that you can use (go ahead, have a little party) that also serves as a guide. If you have a treatment plan template it serves the same purpose as those treatment planners, directing what to include in treatment and how to talk to clients about it.

Join the Private Practice Paperwork Crash Course for a specific lesson on treatment planning and the free template you can start using with clients right away.

Better, Faster Treatment Plans

Treatment plans are the number one thing people search on Google to find QA Prep! That tells me there are LOTS of questions from mental health therapists about this topic.

In this quick video I'm sharing with you one easy way you can improve the quality of your treatment plans while also saving yourself time.

Not too keen on watching a video? Then read the highlights below!

I'm not quite sure why treatment planning turned into something we have to do for paperwork's sake instead of something we do for a real purpose. But unfortunately, it did. And I hope to change that with this tip: 

One easy way to make your treatment plans more meaningful to you and your clients is to write the treatment plan with the client in the room.

I know, I know... a lot of clinicians don't like to do this! They're worried that doing paperwork with a client will negatively impact the relationship and create a barrier. However, when done with care, it actually has a different impact. 

Here are some benefits of writing treatment plans with clients:

  • You'll be able to use your client's own words to describe their concerns, needs and goals

  • You're able to receive immediate feedback on what they want out of therapy or how they view the counseling process

  • You can share with them what your involvement is in the therapeutic process

So, if you've never tried doing this before and treatment plans are a hassle for you, try it out!

Let us know what you think in the comments below.

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.

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!

How to Supervise Clinical Documentation

Although some counselors may feel “okay” about their own documentation, few know how to teach this skills to supervisees. And if you struggled with documentation or feel less confident then this becomes even more of an issue.

In this post I’m laying it all out for you… how to train supervisees, how to correct work when needed and how to integrate this teaching into your supervision so it doesn’t take away from the clinical conversations you need to have. So check out the steps below and see if any (or all!) seem like good things to try out with your supervisees.

Reviewing paperwork

1. Read through the notes as a story, not one by one.

The tendency when reviewing notes is to read them week by week for each client. However, when you read only one session note you miss out on the whole clinical picture. Was there something important that was never followed up on? Does the treatment seem to be following a good flow? Have there been any patterns that emerge over time?

2. Check to see if the reason for treatment is clear.

Can you tell, just from reading the assessment and intake notes, why this client is here for treatment? Are you able to identify a clinical need or goals from the client? These should all be evident in the paperwork but should also match your supervisee’s description when you discuss the case.

3. Make notes about what questions come up as you read.

It’s very easy to get caught up in reading a file and forget key points along the way. Use a simple sheet of paper to jot down comments and notes to yourself. Don’t forget to highlight things that are well-written so you can also give positive feedback!

Training on paperwork

1. Write notes together.

One easy way to train is to simply write the notes in your supervision meeting while talking with the supervisee about the session. This allows you to teach them how to summarize and highlight what are the important points while leaving out “fluff” or extraneous details. Another method to this is to watch a sample therapy session together and write notes on the session individually, then share how your notes are similar or different and see what you each focus on. I’ve experienced great success using this strategy with even seasoned clinicians. If you have a group practice or supervise more than one person, this is a great group technique!

2. Talk about treatment planning and how that looks in real life.

Don’t neglect treatment planning with your supervisees. What I find when I talk with therapists about their treatment plans more often is that they tend to adjust them more often. And that’s okay! Check in to see where treatment is going and if things need to shift. That may mean the treatment needs to shift a little to better meet the client’s needs or it may mean the treatment plan needs to be adjusted.

3. Review one file each meeting.

This will insure the notes are getting done, which is a big piece about documentation! It’s very easy for counselors to fall behind in notes but if you’re regularly reviewing at least one file you’re more likely to see a completed file or to at least catch a problem early. This will also create a habit of reviewing files for both of you.

4. Create an action plan for catching up on notes. Keep them accountable to it.

This is HUGE! As soon as even 1-2 notes are missing, make a plan to catch up and check in. As the supervisor, I do believe it’s your job to follow up and make sure this doesn’t become a bigger problem. Be supportive but also create a firm deadline and provide the needed time to meet that deadline.

5. Have your supervisees attend a training. Even better, attend together!

Shameless plug here, I’ve got a couple trainings on this topic, at different levels of intensity. Check out the Meaningful Documentation Academy to see if investing in even just a 45 minute training may help your team. Part of the reason I do what I do is that not many others are doing it so I don’t have a ton of other resources to give in this area, but seek out your local professional association to see if they’d be willing to sponsor a training on clinical documentation. When these do occur, they’re typically very highly attended.

And if you're reading this is a supervisee, suggest some of these with your supervisor! Many supervisors are nervous about documentation as well but if you start the conversation, they are likely to help you out.

Now tell us… what strategies did your supervisor use that helped you with documentation? Any lessons learned that you can share? I’d love to hear in the comments below!

Writing Therapy Notes: The Advice I Give Every Counselor

Do you ever find yourself saying the same thing over and over again? I talk with hundreds of therapists and I certainly find myself sharing the same pieces of advice each month. 

So what better use of a blog than to write down those most commonly given tips on writing notes?! Below are my most common answers when presented with various problems or questions related to notes... 

Choose a theme for the session

Take a moment to think about the main topic you and your client (or clients) reviewed in the session. You may have jumped around to a few different things but don't focus on the minor details. Stick with the general theme and leave the rest out!

Note: Of course, any time there are safety concerns, this rule goes out the window and you want to carefully document your actions. 

Create a regular schedule

Many therapists think they'll squeeze in a few notes between sessions or randomly complete them throughout the week. Ever hear that saying "Fail to plan and plan to fail"... yeah, that totally applies here. Make sure you have time to do your notes that is separate from time you plan to spend on other administrative tasks (like answering emails and phone calls). 

And make your schedule realistic. Do the math to see how much time you'll need. For example, if you see 15 clients per week and spend about 10 minutes per note that is 2.5 hours you should plan to spend each week on notes. 

That's pretty reasonable for most people... but if the thought of spending two and a half hours (or more) on notes each week for the rest of your career makes you want to throw up, consider checking out collaborative documentation for at least some of your clients. You have options, but make sure you figure out what works best for you so you can be successful. 

Simplify your template

Many therapists start out in private practice using all the documentation techniques their previous supervisor used. But (a lot of the time) that doesn't work out so well. I'm assuming you started a private practice to have some freedom in the way you do therapy and guess what, that applies to your notes, too!

Choose a simple template you can use with all your clients and stick to it. If you want to try out a few different ones, I recommend staying consistent for at least 1-2 weeks to see if you like it. Once you get the hang of writing the same way consistently, you'll have to think about your notes less. They'll start to flow. 

If you want some tutoring on various templates and how to use them, check out my free Private Practice Paperwork Crash Course. I go through four different templates- DAP, GIRP, PAIP and SOAP. 

Wait on using check boxes

This is a biggie. Lots of counselors ask me for check boxes, how to create notes with check boxes, lists of interventions, etc. The thing is, I could give you a list with hundreds of options but that would just be overwhelming. And there's no way I can personalize something like that for you without first evaluating quite a few of your notes, your therapy style and getting a sense of your typical client.

So my recommendation is to create the easy template with check boxes later. First, write your notes using a sentence structure and one of the templates described earlier. Then, after you've been in practice for 6-12 months, evaluate all your notes and pick out the common interventions you provide. You can do this exercise in about an hour. 

Do that and you'll have a very personalized list that will truly save you time, rather than searching through some pre-made template where half the options don't apply to you. You can click here to watch my interview with Rajani Levis, a therapist in San Francisco who used this method to create her own notes template. 

Be wary of taking "quick notes"

Many therapists fall into the trap of jotting down a few quick notes to themselves at the end of a session, with the intention to write the full note later, tomorrow, etc. It seems like a good idea initially because you're making sure you don't forget something, knowing you don't have time to write the note at this moment... but this actually creates a false sense of security.

What commonly happens is the therapist holds off on writing notes, thinking they've got everything covered. Then the pile snowballs and five months later they have hundreds of notes to write (yes, literally... this happens a A LOT). 

Obviously, no one wants to end up in the same situation without the quickie notes to remind them of what actually happened three months ago in that one session with so and so. But I have a theory that most therapists who get behind never would have let themselves get to that point if they didn't have those notes as a "safety net." 

Seriously, if you follow these five tips you will find yourself avoiding many of the problems counselors commonly run into. 

"Did she just say commonly run into?" Yup, I did! Because most therapists do fall behind on their notes at some point. And most therapists feel insecure about their note writing skills.

My personal mission is to change all that, for good! I want to make sure we all have the support we need to succeed.

That's why I created the free Private Practice Paperwork Crash Course, write weekly blogs, do monthly webinars (found in the Meaningful Documentation Academy) and all kinds of other things... to eventually replace this fear of documentation with confidence and, dare I say... excitement!

You can also learn more about writing notes (and get 2 NBCC approved CE credits) through my workshop The Counselor's Guide to Writing Notes** or learn some great tips from my ebook Workflow Therapy: Time Management and Simple Systems for Counselor's.

It's a journey, a process, and I'm here with you for the long haul. So make sure you share these resources and let's keep encouraging one another whenever we can. 

Until next time, happy writing!

**The Counselor's Guide to Writing Notes is now exclusively available through the Meaningful Documentation Academy.

How To Review Goals With Your Clients

Continuing with the "review" series we're talking about goals. And we can't talk about how to review goals without first talking about what they actually are to therapy.

Goals are crucial to therapy. Yep, that's bold and I said it. But it doesn't mean you have to create SMART goals or that your goals have to include a baseline or even be really insightful. 

And you know why? Because they're the client's goals, not your goals. 

Really let that sink in for a minute. Most of the discussion around goals and treatment planning involves looking to requirements from insurance or an agency or what someone taught you "should" be done or is best practice. 

True, you may need to consider some of those things if you contract with insurance or if you still work for an agency. But the concept is still the same, no matter what form the goals take. These are for the client.

When you put goals in that perspective it becomes much easier to review with your clients. It's just a natural conversation about therapy, what is working and where the client would like to be.

I recommend starting this conversation right away but if you've never had it, today is a great day to start! Simply ask your client about how they think therapy is working for them. What has been successful or useful so far? What hasn't been? Is there anything different they'd like to see?

Then there is the big one (which hopefully you start out with from session one or two): How will they know therapy was a "success" (or whatever other word you want to use)? How will they know it's time to end treatment? What would things look like, how would they and/or their situation be different?

Notice that while this is a somewhat directed conversation it is also very client-centered. This works easily with most modalities, couples, families, kids, etc. 

But I know you're still wondering about the format, so I'll give it to you :)

You can choose whatever method works best. Perhaps you simply write down the client's quote. Or you have them write out a sentence. Maybe they draw it instead (yup, you could do that!).

Maybe you need something more formal for your job or insurance so translate that part into your required format... but don't lose out on the exceptional meaning that can be had from really involving your client in the goals process.

If you like more structure you can use the SMART (Specific, Measurable, Attainable, Relevant and Timebound) format to create a specific goal. You could also use your own format. I recommend at least identifying the goal, how you plan to help the client achieve the goal, how the client plans to interact in therapy to achieve the goal, and leave some space for success and highlights of progress.

BAM! You've just created a treatment plan!!

Little bonus for you... and you thought we were only talking about goals ;)

Anyway, once you have established goals (or a treatment plan) then identify timeframes for checking in. Maybe it comes up naturally as a part of the discussion in therapy one day. Go for it! Review away.

But oftentimes we get sidetracked or things morph as the therapeutic relationship develops. That's okay. That's what it's time to say "Hey, three months ago we identified this goal. What do you think about it now? Are we still moving in that direction or should we change course? Anything else we should be working on?"

Book a time in your calendar or set some sort of reminder to follow up and see that the goal(s) still applies, you're on track and nothing else needs to be added. Then adjust as needed, set the reminder for another timeframe and follow up again. 

What's a good timeframe? Well, that depends on your client and the goal. Generally speaking though, I recommend checking in at 3-6 months. It would be a shame to review a goal a year later and have your client feel like they really went off track for a whole year!

Your timeframe may be much shorter (1 month, etc.) depending on the type of goal but that's what is so great about therapy- it's truly individualized to each person. So do what works for your client.

But don't be afraid to take the lead on checking in and making sure you're both on the same page. And be open to whatever the conversation may bring. I seriously doubt it won't be a valuable conversation. 

Write in the comments below and let me know what you think! Sometimes these discussions are scary for therapists but we're all here to support you. 

How Do I Document Play Therapy?

How to document play therapy.jpg

One of the things lots of therapists ask me about is how they should write notes when they have a specialization. The quick answer is that you don't really need to do anything differently! But let me explain more...

When you're providing a specific type of therapeutic intervention, that intervention has a purpose. For example, if you do equine therapy you are doing that for a reason. There is something about the interaction that engages clients and makes a clinical impact.

Similarly with something like art therapy or play therapy. When you provide play therapy, for example, the method is different but the purpose is the same. 

You may use dolls to offer reframes or to explain boundaries. You may use a game to encourage positive verbal communication and manage anger. You may use an art project to process trauma or to assess family interaction. 

The point is not really the method. Therapists use all sorts of methods to obtain the same result. CBT, psychoanalysis, the Gottman Method, DBT are all different ways to provide interactions and connect with your client.

Of course, if you do follow a specific method that makes listing your interventions even easier because of the shared language that is common among many methodologies. However, you can apply those same interventions in many ways.

So rather than simply writing "Therapist played with child using figurines" you could write something like "Therapist used figurines in sand tray to assist client with identifying common interactions within the family and practice alternative ways to respond to parents."

Rather than writing "Therapist utilized art therapy with client" you could write "Therapist assigned client art project to identify triggers to anger."

In these instances it's very clear you're not "just playing" but instead are providing clear, therapeutic interventions. 

So the next time you are writing notes for play therapy (or art therapy anything else "Out of the Box") ask yourself why you chose to use that modality. What was the goal you wanted to achieve? And that's what to focus on in your note.

What other tips or pointers do you have? Any further questions? Feel free to drop us a line in the comments below!

And then keep doing all that awesome work you do. 

Why Your Documentation Is a Mess

I've seen some pretty crazy stuff in client files... like, pretty bad! But you know what's most surprising about finding those things? 

In most cases the therapist had no clue their documentation was a mess.

We're talking like, 99% of the time here. That's not to say they didn't feel a little hesitant. And most of them really disliked doing paperwork. But they had no idea what they were doing made their documentation look so bad.

So I thought I'd share with you some things I've noticed after reviewing hundreds of client files...

The sequence of documentation is super important.

A client's file should tell a clear story. You may have heard that before but let's really look at what this means. 

Most therapists have everything in sections and it's all in a vacuum. The administrative paperwork here. The notes there. Some other random stuff after that. Maybe a treatment plan thrown in the middle.

But what if we put it all together as one story? It's all about looking at the file from intake to where you are right now.

Those initial conversations (your intake and administrative paperwork) led into a treatment plan which led into notes about how you're actually working on that treatment plan. And that leads in to revisions as needed until you have closing paperwork. 

It creates a smooth, easy flow... like calm waves. It's not choppy and chaotic.

Treatment plans, write them out at least a little.

A lot of counselors have a wonderful plan for treatment... in their head. But they never put it down on paper. I talk about some reasons why here in this blog post

Writing it out (even just a couple of sentences) can make a huge impact, for a lot of reasons. It helps keep you on track. It helps you and your client evaluate what's working. And if you bill insurance, it lets them know you're meeting medical necessity guidelines (read more about that here).

Keep your focus on the important things.

When you're writing notes, leave out all the extraneous info (getting people water, the nitty gritty details of a story the client told). Keep it simple and focused. Try keeping each section down to 2-3 sentences. 

Unless you had a crisis session, there really shouldn't be much more than that. Focus on what you did and how your client responded. Note anything that stuck out to you as important or odd. Include the next time you'll see your client. 

And leave it at that.

Review your charts from a storytelling perspective. 

A lot of times what I see in client files doesn't make sense. It takes me a long time to review because the story is disjointed. I need to flip back and forth. Or something is missing and I keep searching to find it.

It takes me a loooooonnnng time to review a messy chart.

However, when a file reads like a story it's so much easier to review. One day flows in to the next and there aren't any big surprises. The interpretation matches the objective info presented and I can clearly see what the therapist is thinking.

I encourage you to go through one of your client's files this week. View it as a story. Does it make sense chronologically? Are there any missing pieces? Do your interpretations make sense with what is presented by the client?

And is it easy to read?

Then head back over here and let us know how it goes! And if you haven't already done so, sign up for my weekly newsletter (and get access to my free Private Practice Paperwork Crash Course) where I send special tips and resources to help you along the documentation journey. 

Cleaning up a mess is much easier with help, so don't be afraid to ask for it! Happy writing :)

Why Your Clients Don't Fit With A Treatment Plan

We all know the ethical thing to do is to have a treatment plan for each client but you want to know a secret? Most therapists don't have one. And of the few that do, most don't follow it. 

So I thought I'd break down some of the common misconceptions and mistakes around treatment planning in psychotherapy. That way you can evaluate your own process.

Most counselors don’t write out their treatment plans. It’s in your head but not on paper. Why the hesitation to write it down? Because you know your client's needs will change, the focus of treatment may change, and you think why write it down when it won't apply a few months from now?

Or maybe you're just a little behind on paperwork and don't feel like writing that up when you still have to catch up notes... more about that in just a couple weeks.

Another reason is that the term "treatment plan" is a bit ambiguous without a framework. And ambiguity often leads to inaction. How long should a treatment plan be? How structured do the goals need to be? When do I make changes? Do I need to reference it in my notes?

There's no definitive answer for these questions so most therapists just avoid the whole task altogether. If there's no clear standard, there's no way for anyone to hold you to anything, anyway.

And for those who do write up a treatment plan, they make one really common mistake- not following it. This is often because you may not want to adjust it. Or you forget to adjust it. Or you write it up out of duty and put it away to never reference again. 

But you have to, we have to meet our clients where they are and so often that changes over time. No big deal. Adjust it as you need because treatment plans should be fluid, not keeping you stuck.

If you've read most of my blogs you've likely heard my recommendation to read through 1-2 of your client's files at regular intervals. This is a great time to check up on that treatment plan and see if it seems to make sense with what your notes are saying. If not, there's typically one of two things happening...

  1. Your treatment plan needs to be adjusted because your client's needs have changed. This is easy! Just follow the recommendations I've already mentioned.
  2. You're getting caught up in the mundane weekly stuff your client brings to session rather than keeping a general focus. Of course, the types of goals you set will vary greatly depending on your style and modality of treatment, but in general you want to help your client identify an end game so the two of you can evaluate things along the way.

Want a little more detail, like a step-by-step training and walk-through? You're in luck! Sign up for my October video training series**. In this week's video I show you how to write the easiest treatment plan you've ever created. 

And leave a comment below with your favorite strategies for writing a treatment plan. We all become better when we share strategies. Happy writing!

**This training is no longer running, but you can always sign up for my FREE Private Practice Paperwork Crash Course, or check out my Meaningful Documentation Academy for tips, trainings, and more!

5 Steps to an Effective Treatment Plan

I've had so many of you ask for a blog on treatment plans... so here it is! Actually, here is the first of many, I'm sure. 

To be honest, I hesitated writing a post about treatment planning because it is such a vague yet sometimes polarizing topic. Some therapists yearn for detailed treatment plans they can easily follow while others scoff at the idea of trying to put on paper what really happens throughout our time with clients. 

A couple things we know for sure- 1) talking with clients about progress makes therapy more effective and meaningful for clients and 2) most ethical guidelines state that a therapist or counselor should have a treatment plan in mind while working with clients.

That's all well and good but what does that really LOOK like?! I've outlined five step-by-step principles you can use for treatment planning with any client in any setting. And then I'm offering you the ultimate tool- a template that puts this in action. 

1. Goals (or objectives)

Every good treatment plan starts with a clear goal (or set of goals). Identify what your client would like to work on and write it down. Don't be scared of limiting your work, you can always adjust these as time goes on. However, it's helpful to write down and discuss what your client's purpose is for starting therapy. How will they know they are on the right path? What will you both use to determine when the client is ready to terminate?

Having a clear goal makes sure everyone is on the same page and keeps you both accountable to focusing on what is necessary. It also helps your client to feel like therapy is something that is more than esoteric, something they could describe to a spouse or family member, if desired.

2. Active participation

A treatment plan then follows up with how each party will work to achieve the goal(s). This is really important and often missed. Talk with your client about your role as a counselor and how you plan to help them achieve their desired outcome. This opens up a great discussion about the role of a counselor and how therapy looks with you, specifically, as compared with others.

The other key piece here is how the client will participate. This is where you have the opportunity to explain what is expected of them and that you're not there to simply "fix" anyone. Therapy is often hard work but can have amazing results. However, success is 100% dependent on the client's motivation and willingness to engage in the process.

3. Support

Another aspect of treatment planning that is so often forgotten in private practice settings is the client's support system. It's not just you and the client against the world. They'll need other supports in place to be successful throughout life. Identify any support as part of your treatment plan and you have already shown your client some of the tools in their toolbox. 

Get creative here. Perhaps the client's support is a family member or friend but it could also be a pet or a support group. Maybe it's a hobby or spiritual practice that helps keep them grounded. Perhaps some character traits like being fiscally responsible, planning ahead or being very outgoing or creative. These are all supportive things that help the client reach their goals.

4. Outcomes

The last important aspect of the written plan is the outcomes, or success. Make sure to write these down at various intervals. Maybe you visit the outcomes so far once a month, maybe every three months, etc. Choose what interval works best for your client and your style and make sure to plan to talk with them about it. 

Is this still the primary goal or do we need to adjust something? Are we staying on track with these? If not, is time to redirect or do we need to revisit some things? What success have we made and what contributed to that? What will we continue to do in order to reach that goal? 

And once you do clearly reach that goal, have we discovered other things through the process that we need to prioritize? Is it time to talk about termination and what will that look like? I could go on and on. The clinical material is just waiting to be discussed!

5. Client involvement

I've save the most important step to effective treatment planning for last. Involving your clients is crucial. Without their feedback, your treatment plan is no more meaningful than a term paper with a bunch of words on it. Remember, your documentation serves you and the client, not the other way around!

This is an ongoing conversation to have throughout treatment. Treatment planning isn't something you do at the first or second session and then forget about. It's an integral part of the counseling process. It's a clinical discussion that's simply put on paper to provide a clear outline and clearer understanding of the direction in which you plan to go. 

I've created a template using these five steps as the foundation. You are welcome to download the template and use in your own practice, or modify it to better suit your style and client population. I love seeing how people adjust my templates and personalize them so if you do make changes, share them by emailing me or leave a comment below. 

To access the template, simply sign up for my free Private Practice Paperwork Crash Course. I've got lots of goodies in there, along with some more direction for you on treatment planning. I wish you all the best using it with your clients!