Make Notes Matter for Your Client: 5 Strategies You Can Use Today

I talk a lot about notes. People ask me a lot about notes. Therapists write a TON of notes!

However, the really ironic thing is that we rarely consider how notes actually matter for clients. We just write them out of duty, and often with disdain.

Now, if you've decided that you hate writing notes, you'll always hate writing notes, and there's absolutely nothing that can be done about it, you're right. Nothing will change and you'll spend your entire career resentful about what probably takes up at least 25% (if not 50%) of your work time.

However, if you dare to consider the possibility that notes could actually have value for your clients, I guarantee you'll see a considerable shift in your feelings about writing notes.

I'm not talking about the legal stuff or insurance here. We all know that notes have value as a source of proving you provided a service or showing you acted ethically when seeing a client. But let's face it, that's not a very motivating factor for most counselors. 

You need a connection to the transformation you see in the room. 

I get it. So I've got some strategies to help you cross that bridge from mundane to meaningful. 

1. Identify your client's voice. Progress notes are a way for you to help identify your client's thoughts, insights, and story. You are translating the (sometimes messy) process in the room. Help them tell their story as the final step in your session.

2. Picture your client next to you when writing. If you imagine that your client were reading each note it changes the way you write. And you know what? That's a real possibility. It's rare, but it could happen. Your clients have the right to see their notes. So consider their their feelings, their interpretation. What would stand out to them and what is their takeaway?

3. Imagine your client telling a close friend about the session. Similar to the above, this strategy helps you to make writing notes a truly reflective process. Stop for a minute and think "what would my client say about this session?" What feelings would they identify? What seemed to matter most to them? What would they say about your actions and responses during the session?

4. Get your client involved. One strategy that scares a lot of therapists is to actually include their clients in the note-writing process. I explain this strategy in detail in this blog post. This isn't for everyone but it can be very empowering for both the client and the therapist who struggles with time management. It's fascinating to review with your clients how they would document each session and often creates a greater understanding of the process as a whole. 

5. Imagine this as a journal entry. Your notes are a way of documenting your client's journey in treatment with you. Sometimes this simple mindset shift can create more meaning. These notes are more than just a legal document, they're your way to look back on success and powerful moments later on.

It's hard to think of notes as boring and mundane when you look at them through this lens. This is the approach I take with all documentation and I hope it creates true meaning for you. If you're interested in a free training series on making notes more meaningful, click here.**

I love sharing new strategies and creating ways to make meaning for therapists. If you've got some tips of your own, feel free to comment below and share with us!

In the meantime, happy (meaningful) writing!

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

The Fastest Way to Write Your Notes

Not surprisingly, most counselors are looking for any way to make writing notes faster. The most common method for doing this is to skimp on content or just avoid writing altogether (um, NOT what I'd recommend, btw). 

I hear from therapists every week who are behind in their notes.... and I'm not talking one or two days behind. I'm talking weeks, sometimes months behind in notes. Yes, it's that common. 

Feeling better already? Good! Now let's get you rocking those notes in no time.

Prepare yourself, because your initial reaction will be to balk at my recommendation. But if you're behind in notes, it is likely going to lift a huge burden off your shoulders if you really implement it... I'm talking about collaborative documentation (sometimes also called concurrent documentation). 

That's right, actually writing your notes with the client in the room. By the time your client leaves your note for that session is done. You see your next client (or go home) without worrying about any notes to complete. 

Sounds a little bit weird but a lot awesome, right?

Now some of you may have had a negative experience with this from working in an agency. But I'm going to outline how to get this done in a clinically powerful way. So stay with me here...

What is collaborative documentation?

Collaborative documentation is writing your session notes in conjunction with your client. It's not the same as jotting down your thoughts on a "secret" notepad you hold between you and your client. It's actually including your client in the note-writing process.

At the end of the session, you and your client transition to talking about what just transpired. What insights were discovered? What progress was made? What was learned? What action will be taken before next week?

I know, I know. You're thinking, "I hate writing notes. Why would my client want to do that?"

Well, there's actually a good body of research that shows clients like it! Why in the world would that be?

Here are some of the benefits of collaborative documentation...

It increases client involvement. Yup, that's a bold claim but it's true... provided you keep one key thing as the focus. This is your chance to get honest feedback from your client.

We know that consistently asking clients for feedback and reviewing progress improves therapy outcomes all the way around- engagement increases (e.g. no more no shows) and clients report being more satisfied with the process. 

Use this opportunity to reflect with your clients on how that session went for them. What stood out to them as the main focus? What stood out to them as something they could do differently over the next week? What insight surprised or motivated them?

Have the discussion and write it down together. Voila, you're done!

It creates transparency. The old-school thinking of us (the "experts") and them (the patient) is quickly fading. People are no longer satisfied to blindly follow advice. They research things ahead of time (hello, Google!) and know their rights. 

When you're transparent about the notes you take for sessions it increases the amount of trust built in the therapy relationship. Your client no longer feels as though you're hiding something and wonders about it. 

It makes you think about your notes differently. Trust me, you'll think about notes differently when your client is watching you write them. The note will automatically have more meaning. It becomes personal. 

Rather than something required by a licensing board or insurance company, your client notes become what I like to call the record of your client's journey with you. It's almost like a journal you write together. Bet you've never heard that analogy about notes before!

It provides you the means to transition and end sessions on time. One of the most common things I hear from counselors who have difficult writing notes regularly is that they end up with very little time between sessions because it's difficult for them to end session on time.

Now, that's partly a clinical issue I'd encourage you to consult with someone about but some of it is just lack of training in how to gracefully transition your clients. Introducing this as a closing exercise can be a nice way to provide that transition for clients who have difficulty respecting that boundary. 

So, what do you think? Are you thinking about trying it out? I recommend you try it for at least two weeks to give it a fair shot. The first few times may be a bit awkward, so give yourself (and your clients) time to get used to the process and individualize it a bit. 

Then jump back over here and let us know how it's going! 

Looking for more tips on saving time while keeping your notes awesome? Check out my October training series.** We're going to rock your documentation in just four weeks with weekly videos and webinars on all things paperwork.

Happy writing!

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

**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!

The Fear and Loathing of Documentation

Let's be honest, part of the reason this site even exists is because many counselors have two main feelings related to documentation: fear and loathing. I hope things like the blog and my Crash Course help to lessen some of that but I know it's an ongoing struggle.

But why? I mean, we're talking about people with Master's Degrees and Doctorates here! What in the world is so scary about a little bit of paperwork for someone who wrote a thesis or dissertation? 

Many therapists talk about documentation like it's this huge task because they truly feel that way. But they often don't take the time to examine why, and even fewer take the time to do anything about it. 

I'm a firm believer in identifying fears as the first step to moving through them. So let's take an honest look at the fears around psychotherapy notes... and some strategies for overcoming these fears.

1. Fear you're not writing your notes the "right way"

This is what I hear from most therapists I talk with. They're in private practice and no one ever looks at their notes. They had minimal training during internship or they were trained in a very specific format geared toward an agency. 

The truth is, there's no "right way" to write notes for private practice! As with many things in life, there are guidelines to follow but not specific rules. And I personally think that's a good thing!

You have the freedom to personalize your notes to your clients, to a specific population or your methodology. I recommend creating a structure for yourself by trying out a few different templates and then sticking with what works for you. Don't limit yourself but don't overthink it. 

Check out how one therapist did this for her EMDR practice by clicking here.

2. Fear you're not doing good work

Ouch, yes, this a truth bomb. But some counselors are simply scared of other professionals seeing the clinical work they're doing. The fear goes beyond just writing notes "the right way" and in to wondering if they're even providing good clinical care.

In this case, the best solution is getting good clinical consultation. I'm not talking about posting a question to a Facebook group and weeding through 37 responses by clinicians you've never met. I'm talking about a real phone (or live) conversation with a colleague who specializes in the area in which you have questions.

Ask your previous supervisors, classmates or suitemates for consultation or a referral for someone they know. Do some research online. Whatever you do, build a good network of 3-5 colleagues you can call when you have a question, get stuck or just need some encouragement.

Remember, in any questionable case you'll be judged by whether or not you acted ethically based on what your peers perceive. Keeping a pulse on that is crucial. It also serves to continually challenge you as a clinician.

3. Fear your notes will hurt your client

Speaking of ethical situations, another common concern I hear from therapists is that if their notes are ever presented in court those notes will inevitably hurt, rather than help, their client. 

First of all, there's some validity to this fear... because it has happened. And I can't guarantee you it will never happen to you. But I can show you how to craft your notes so they serve a (meaningful) purpose and minimize risk in all areas. 

The key is to make sure your notes tell a story. I like to think of notes as the story of your client's journey in treatment... the abridged version. They don't have to go through every gory detail but they do need to let the reader see a glimpse into the room. 

It's a delicate balance of writing enough to show you acted ethically and can jog your memory years down the line if needed while also avoiding a transcript of words that could potentially be twisted later on. 

If you're struggling with how to do this, I encourage you to consider signing up for a consultation with me. We can go through your notes together, without judgement and without fear of any retribution. 

I strongly believe that most therapists can overcome their documentation fears and make writing notes a meaningful practice. This is my mission with QA Prep- to take something that is meant to be valuable (but often ends up being a chore) and infuse some life into it. 

Do you relate to any of these fears? Feel free to share you thoughts in the comment section below. 

Couples Counseling Notes: 4 Steps to Simplifying the Process

Couples counseling is different from individual therapy in a lot of ways, but are the notes and paperwork any different? I've gotten this question from lots of therapists. 

The short answer is no, the notes really aren't that different from individual therapy but the long answer is, it really depends on your practice. As we reviewed in a video with Rajani Venkatraman Levis, your notes can be made much more meaningful by tailoring them to your practice.

Couples therapy notes work the same way. You can use the basic principles of writing psychotherapy notes and then adjust based on your practice's needs. Here are some ways you can personalize couples therapy notes:

  1. Incorporate your favorite modality. In my interview with Rajani she talks about how she adjusted her notes to suit the type of therapy she does, mostly trauma work and EMDR. If you are a Gottman trained therapist, use that language. What are the key principles you review with couples? What are the common exercises you have them do at home? Write these down over the next week or two and bam! You've got your own cheat sheet (that you can now modify and add to as needed). 
  2. Identify patterns. If you follow a similar pattern with most couples, identify the steps. Do you always cover certain topics in your first 1-2 sessions (things like confidentiality and keeping secrets)? Perhaps you have certain things you do in the first month or in the first phase of treatment. Perhaps you have exercises you assign near the end of the counseling period. Create a timeline of how couples counseling looks with you and have that handy when you write your notes. It will often make the process much easier because it prompts you to remember things you sometimes forget. 
  3. Focus on interaction. Case notes are really all about interaction. In couples notes that's magnified because you not only have the interaction between client and therapist but between the two clients as well. I like to break down notes into focusing on two main things, therapist action and client action (or reaction). Note what you bring to the table- assignments you make, methods you teach, insights you give. And note what the couple brings to the table- the responses they give, the way they interact, the information they provide, the progress they make. Thinking of notes in this way really highlights the clinical nature of note-writing and makes it more interesting. 
  4. Inform the couple. Couples counseling does have one big difference from individual counseling- the confidentiality piece. It's very important to inform couples of your record keeping practices from the start. In my experience, about half of therapists keep one "couples record" because they view the couple as a whole client. The other half of therapists keep separate records for each half of the couple, essentially creating two clients. Regardless of what you choose to do, make sure you explain this to the couple so they are not surprised, should they ever ask for copies of their records. And as I recommend with all policies, once you decide on a method, stick to it.

And that's it! Well, we could go on but I'll leave that for another post. What do you think? If you're a couples therapist and have more tips or insight, please add a comment below!

And if you're a little stuck because you want more of the basics on note writing, check out my free Private Practice Paperwork Crash Course. I give you two weeks of quick video training on forms, notes, treatment plans and more. And if you're looking for more in-depth help, I also offer individual consultation packages

Either way, hope you find this helpful for making your notes easier! Happy writing.

Creating a Meaningful Template for Your Practice

This month's training video has a different spin and I really think you'll enjoy it. I'm talking with Rajani Venkatraman Levis, a Licensed Marriage and Family Therapist and Certified Trauma Specialist.

Rajani created her own template for her notes to save herself time and energy on her documentation... but she did it without sacrificing the individualized component of her notes. So we dig into how she did that and how it has impacted her practice. 

We talk about clinical care, the emotions related to private practice and how all that can be used to infuse meaning into your documentation. I truly hope it will inspire you as well as give you some practical tips on how you might make your documentation more meaningful and less time-consuming. 

Please comment below if you have any additional tips or feedback to create meaning with your documentation, or if you have a question for Rajani or myself. 

And if you're feeling inspired but still a bit overwhelmed, check out my individual consultation packages. I can help you put the work up front to save yourself time for years to come, just like Rajani did. 

When You Need to Think Like an Agency

Most counselors in private practice are accidental small business owners. They love the idea of having a private practice- the flexibility with scheduling, choosing their own clients, and the ability to have their own private office space.

However, they typically don't enjoy many of the business-related tasks with owning a private practice. They rarely think of their practice as a business but rather see themselves as a simple service professional. 

Regardless of the size of your practice, there are times to think like a business, and more specifically, to think like an agency. That's right- sometimes you actually need to think like an agency in order to protect your practice and also improve the work you provide your clients. 

You may be thinking "but I left an agency so I could actually do what I think is better work for my clients!" This is often true and the two ideas are not mutually exclusive. Let me explain...

Agencies have a lot of liability due to the fact that they employ people who are often dealing with complex clinical issues and safety risks. For that reason, they need to create policies and procedures, train employees on these P & P's, and regularly evaluate the effectiveness of the work they're doing. 

Now let's be honest. Some agencies do a really poor job of this. I'm not disputing that fact. However, the principles are excellent. They create a safety net when working in high risk situations and seek to provide guidance for dilemmas before they arise. 

Maybe you're sold on the idea but the thought of implementing sounds like a monumental task. Not so! Here are four things you can do to improve your psychotherapy practice that you can implement in an hour or less:

  1. Write out your sliding scale policy. This is an area that presents a lot of resentment and confusion for counselors in private practice. Many therapists decide on a sliding scale on a whim and few ever outline criteria for determining their scale or a timeline for reevaluating the client's need. Consider the clients who are currently on a sliding scale. Consider your ideal client population. How many sliding scale slots can you reasonably maintain and at what rate? Will you require proof of income/need? For how long will you provide the sliding rate? Answer these questions and bam! You've got a policy. 
  2. Write our your consultation procedure. Ethical dilemmas arise (and usually at the worst possible time). Client needs change and become more complex. In these circumstances it's important to remember you are not an island. There are many other professionals with whom you can consult. Documenting these consultations is important (read more about that here) so write out how you'll do that. Will your consultations be over the phone? Do you have criteria you feel is important to meet before you consult? Do you have certain people with whom you frequently consult? Are you part of an ongoing group for support on clinical issues? Answer these questions and bam! You've got another policy!
  3. Do a review of your client records. I frequently recommend this because it is so valuable. Choose 1-2 records and read through them in entirety. Do you get a good sense of the treatment you're providing? Do you get a good sense of the client's needs? The client's progress? Are there clinically significant things you notice you may be overlooking? This is a great exercise to do when you feel stuck with a client and this is something agencies do on a regular basis to ensure staff are providing good care... as well as keeping up with notes on a regular basis! Which leads me to the last recommendation... 
  4. Decide on a reasonable expectation for getting notes done. In private practice you are your own boss. For some people, that's not always a great thing. I find that one area many counselors behind in is writing notes. It's so easy to decide to just go home and make dinner instead of staying to finish notes. Then you enjoy some family time and go to bed (because you need your rest to write good notes). Then the next day something important comes up and then it's the weekend and your kids have activities planned, and so on and so on. One way to avoid becoming backed up is to create what your business would see as a reasonable expectation for getting notes done (hint: this should be within at least one week of providing the service). Write it down as a policy and stick to it like you're an employee. The key here is that you have the flexibility to make the policy work for you. So consider how that works for you individually and stick to it.

There you have it! Each of those tasks will take less than hour but will greatly improve your business status. They'll also help you to avoid a lot of anxiety-provoking situations and create stability for your practice. 

If you feel like this is still a bit overwhelming, consider booking an individual consultation with me. We can walk through the whole process together and get your documentation handled in no time! 

Leave a comment below if you've tried any of these techniques. What impact did it have on your practice? What lessons did you learn about yourself as a business owner?

Out of the Box Interventions

One question I frequently get is "The therapy I do is not traditional and I don't know if my documentation is okay for that."

I love that our field is so broad and includes a multitude of interventions for different types of clients. I also think it's really important that we continue to try out new things and be at the forefront of change and innovation. Mental health is often slow to do so and I thank all of you who continue to push the boundaries!

So I thought it was important to share how to keep your documentation rock solid while working in the gray areas of therapy and made that this month's video focus. Click below to watch:

What are your thoughts? Share in the comments below!

Client or Patient? The Language We Use in Documentation

When I was working in an agency in 2009 an interesting shift started happening... the word "consumer" started to replace the word "client." And I really disliked it.

To be honest, I got a little self-righteous about it. "How dare we compare the service we provide to services in some store?" "I am not a consumer at my doctor's office!" "This is so offensive."

I refused to engage in the consumer terminology and kept my well-respected "client" in all my notes. And then one of my coworkers (a fabulous therapist, BTW) mentioned something to me in passing... "I don't understand why we don't use the client's name." 

Truthfully, this thought had never even occurred to me! Rather than writing "the client began to cry when talking about her mother" I could write "Julia began crying when talking about her mother."

Wow... do you notice the difference? It feels so much more personal! 

Hold up, Maelisa, these are legal documents. These are professional notes. Can I really do that?

The answer is yes, you can use whatever language you want!

Perhaps you're more traditional and prefer the word "patient." It conveys a certain professionalism, appropriate personal distance, and is very commonly used. (Side note: it also has the added benefit of easily and recognizably being abbreviated to "Pt" for those of you that prefer as little writing as possible)

Perhaps, like I did, you prefer the word "client." This also conveys an appropriate distance and reflection of the relationship while also valuing that therapy is different from other "medical" treatments. 

Perhaps *gasp* you actually prefer the word "consumer." Well, I can't blame you... our clients truly are consumers of a service. We are reminded of that every time issues arise with payment or dissatisfaction. 

Perhaps you prefer the word "member." This is common in insurance circles. While it may currently have a negative connotation for many, the idea behind being an active "member" is really quite noble. It conveys some investment in the service provided. 

Lastly, perhaps you prefer to use the person's name, like my friend and co-worker. That conveys a personal meaning to the notes and you know what, it gets the job done just as well as any other term we create for a sense of professional distance.

The actual phrasing doesn't really matter. What matters is the content, the meaning behind it, the story that unfolds note after note. 

I love when I review a client's file (for another therapist, not a client of my own) and I can picture exactly what it's like to be in the room with that person. I am able to read about their subtleties, personality and nuances. That's what matters.  

So, do what feels comfortable for you. Do what is meaningful to you. Write your client's story of treatment with you. And don't worry about it any more than that. 

What terminology do you use in your documentation and how come? Have you struggled with this topic? Leave a comment below. I'd love to hear about it!

Practical Tips for Easy Case Notes

This week's post is a little different because I'm sharing with you my very first podcast interview! I had a blast talking with Dr. Melvin Varghese from the Selling the Couch Podcast. We talked about intake sessions, building rapport with clients, mindset shifts in documentation and I also shared one of the notes templates I created. 

Click here to listen or download the podcast now.

In my Private Practice Paperwork Crash Course I go over four different templates therapists can use for case notes. I also share my own templates, which I call Meaningful Templates. If you haven't signed up for the free course yet, click here to get it.

When talking with Melvin I shared one of these Meaningful Templates, one called Results-based Notes. For these type of notes, the template is based on reflective questions you ask yourself as you write the note:

  1. What did my client identify as their goal originally (in the first session)?
  2. What would my client say is their current goal and how does that relate to their original goal?
  3. How did we work toward those goals today?

Use these questions to answer how the session was focused. Try answering each related to both your client's involvement as well as your own involvement in the session. 

This format makes writing notes feel very natural while keeping the note focused on the important information to have documented. You can also couple it with a more traditional note template but use the questions as a reflective exercise to prompt yourself while doing case notes. 

As mentioned in the interview with Melvin, I always recommend that you take a couple minutes to calm or center yourself before writing notes. Visualize your client leaving the session and consider what they've learned, how they feel and what actions they might take as a result of the session. 

This makes writing notes feel much more like what it should be- a clinical extension of the session. It's no longer an unrelated task, just "paperwork." 

Try it out over the next week and let me know how it goes! Leave a comment below with your experience and any adjustments you made that you found helpful. And as always, happy writing! 

The Terrifying Truth About Ignoring Your Paperwork

We all know completely ignoring documentation is probably a bad thing, right? And honestly, most therapists don't completely ignore their paperwork (although believe me, there are SOME that actually do!). It's not really that difficult, right? Can't you just copy some forms from an old supervisor, slap on your own logo and address, grab a notepad and some manila folders and get going?

Well, yes and no. You could do what's described above. And you know what, you might be just fine... for thirty or forty years, even. Or you might be in some serious trouble. 

Before we get into the "serious trouble" part let me reiterate that I am NOT into fear-based thinking related to documentation. I'm not trying to scare you or create anxiety; I want to do the opposite. So, let's talk about possible trouble spots and how to avoid them for good...

Policies

We'll start with policies and procedures. When you copy from someone else, even a great supervisor or a form you purchased, you lose the personal aspect of you. I'm all about checking out samples and using templates to make life easier. However, don't just swap out someone else's name for your name!

Read through it. Do these policies make sense for you? For the clients you see? Anything you tend to do differently or always wondered if you could do differently? Then CHANGE IT. Make it meaningful to your practice.

Some therapists have a lawyer check out their policies to make sure everything is on the up and up. I think that's a great idea, but again, make sure the "youness" of your practice doesn't get lost in the shuffle. Can you actually understand what the forms say? If not, go back and change the wording. If you can't understand it, your clients sure as heck won't understand it. And you need to know your forms and policies really well so you explain them to clients and reference them when needed. 

So, three months into treatment, when your client brings up something about payment, missing or rescheduling a session, or wanting to reach out to you via Twitter... you'll be ready! You'll have already reviewed the policies with them so you can offer a friendly reminder... and you can do that ever so gracefully and easily because these are policies that you know, that make sense for everything you do. 

Record Keeping

Which leads me to my next topic- keeping records. While it may seem easy and appealing to just throw some papers in a manila folder, there's a lot more to think about when it comes to storing records. You've just started a long-term relationship with your documentation. That's right, even if your client breaks up with you... you get to keep custody of the records!

Each discipline and state has different guidelines but the common consensus is seven years for adults and for minors, 3-7 years after they turn 18. In other words- a long frickin' time! 

That means it pays to pause and think about HOW you want to keep records long term... from the beginning. I encourage therapists to keep records electronically because it's much easier to store for years. And it doesn't matter if you move offices, states, whatever. If you want help searching for a good electronic record system, check out Eileen at EHRassist for some helpful tips. 

But even if electronic records aren't your thing, you can still make sure to do your records right without things getting complicated...

Think about where you want your forms to go and stick to a specific order in every client file.

Make sure everything is properly secured in the file so you don't lose papers (I cannot tell you how often I've seen this simple mistake!).

Keep things in order by year and name so you can easily search later on.

And make sure you stick to a schedule for writing notes so you know things are up to date.  

Notes

And that brings us to the topic about which I'm asked most! Writing notes. Therapists tend to worry about their notes a lot... And to worry in solitude.

You don't know if your notes are sufficient or too long or whether or not they even make sense. Maybe you worry you share too much. But you have no clue what to do about it because you're not going to bring confidential notes to a networking meeting and ask about it there!

Unfortunately, this means most Counselors then choose to ignore the nagging questions and live with the ambiguity without seeking more guidance. That leads to a lot of ongoing anxiety around documentation and especially leads to panic mode when a request for records or a subpoena shows up. 

My solution? Share and ask! You need a community of therapists you can go to with complex questions. That may be a consultation group you meet with or someone you can call on the phone.  

I also recommend doing a note writing exercise with other therapists. In my Meaningful Documentation program we review a mock session and then everyone writes a note about the session. We all get to see the different styles, share ideas, get confirmation we're doing the "right thing" and with no concerns about sharing client information!  

I've used this exercise a few times with therapists in person and it's usually a little nerve-wracking for people in the beginning. They want to avoid it, like they're used to doing. But once I persuade a few brave souls that there's no judgment and everyone else is just as terrified, they step up.  

They choose to take a chance, to learn and grow as a clinician. And they feel so good about it afterwards! The whole room changes from uncomfortable anxiety to calm.  

Thats why I love training and why I choose to focus on this topic of documentation. You don't have to ignore it and you don't have to live in fear.  

Enrollment in my Meaningful Documentation program is closing tonight. Click here to learn more or to sign up for information on the next round**. 

Happy writing! 

**The Meaningful Documentation program is no longer running, because the feedback was that people wanted...more! So now instead of one short program, I'm offering never-ending access to all of my trainings, information, and even office hours through my Meaningful Documentation Academy.

Making Documentation Meaningful

There are a lot of emotions around documentation for therapists, most of them negative. Fear. Resentment. Overwhelm. Anxiety. Anger. I hear all of these and many more mentioned in networking meetings and Facebook groups. And it's commonplace; like we're just supposed to accept this is how it is and trudge through it for our entire career.

But what if paperwork didn't have to be that way? 

It's now been a year since I started blogging about documentation and I've been getting awesome feedback from therapists around the world. My favorite thing to hear is that I've made someone's work easier by helping them to connect with paperwork. That's right, it really is possible to have positive emotions around paperwork! 

Confidence. Satisfaction. Connection. Peace. Joy. 

So, how is it that some therapists have gone from overwhelm to peace? From anxiety to confidence? I've found that evaluating your mindset and looking at documentation differently can actually make it more meaningful. And that is the operative word for therapists...

Meaningful.

One of my taglines is "Learn to love your paperwork." People often ask me if this is really possible or laugh at the perceived absurdity. I had one person ask me, "Do you REALLY love paperwork?" The honest answer is, it depends. 

Do I love paperwork for the sake of paperwork? Do I love checking off boxes, crossing t's and dotting i's? Do I love poring through mounds of legal documents that are difficult to understand and relate to what I do? Absolutely not!

However, I do love reading the story of someone making a breakthrough. I love writing quotes from clients who have just made an impactful insight. I love writing a report or letter that someone needs in order to access a life-changing service. I also love the feeling of finishing a document I am confident will support me in case questions come up later. 

But how do you go from that place of resenting paperwork and across the bridge to "loving" paperwork? I've found that bridge is Reflection. Taking even 2-5 minutes before writing a clinical note can make all the difference. That time to really focus on the meaning of your session and the clinical outcome gives the paperwork associated with it the value it deserves.

And let's take that even further... what if we viewed our informed consent document not as a required form that needs everyone's signature but as a way to empower our clients and introduce them to parameters of the therapeutic relationship? Because that's the meaning behind an informed consent form. 

Unfortunately, though, many of us have turned these documents into legally required paperwork that we resent and then overlook... and that leads our clients to overlook these things as well. But we have the paper to change that simply with our intention. You can use a Contract for Services or Informed Consent to discuss with your clients the importance and uniqueness of the relationship you'll build over time. 

Doesn't that sound awesome? Imagine if throughout your day documentation was just a reflection of the clinical work you're doing, rather than something disconnected from it! It is possible, it just takes intention. I challenge you to be mindful of this for the next week and be open to the possibility that paperwork can have new meaning. 

And if you're looking for more ways to implement meaning into your documentation, sign up for my free crash course. In it I provide a training on what I call Meaningful Templates, a way to implement these practices more directly into your note writing. 

Now decide on one way you can focus on making paperwork more meaningful in your work. Share below and get support from your colleagues... and happy writing! 

What to Write When You Break Confidentiality

Most of us have been there... that uncomfortable moment when your client is talking about something you know you'll need to report. Even if you've had the unfortunate experience of doing this multiple times, it still causes an unsettling feeling of uncertainty.

Part of that uncertainty comes after the situation is reported and over... when you sit down to write your notes. How much do you write? What do you need to include? What do you want to avoid writing? Will this note cover your butt?

There are a few things you always want to include in your note for that session and a few things you don't want to put in your note. The key here is that you want to provide your rationale for why you broke confidentiality but you don't want to include all the details of the incident itself. 

Include the following:

  • The general reason you needed to break confidentiality (example: client reported an incident of child abuse)
  • Limited details to support this claim (example: client reported her husband beat their son after performing poorly in a sporting event and her son has multiple visible bruises)
  • Your method of reporting the incident (phone call to protective services, online reporting system, etc.)
  • The name of the person you talked with while making the report
  • Any confirmation/reporting number you receive as a result
  • Appropriate plan for follow-up as needed
  • Whether or not you consulted with any colleagues regarding the report and their recommendations

Avoid the following:

  • Further details of the incident- this information should be kept confidential so leave the details to your required reporting form
  • Copies of any reporting forms- keep these in a file separate from your client's personal files

Following these principles should make you feel confident that if anyone reviewed your records they would understand why you needed to break confidentiality to report the incident. They would know that you acted ethically and clearly understand your responsibility. However, they wouldn't be able to recreate an entire play by play of the incident.

As is always the case with confidentiality, provide only the information necessary. Crises and mandated reporting do not give you a free pass to share any and all information. Stick with what is necessary and when in doubt, consult with a trusted colleague. You can even review your note with a colleague to see if they are able to clearly identify why you needed to break confidentiality. Then, engage in an act of self-care! These situations are stressful and take a toll if you don't care for yourself and get the support you need. 

If you'd like more tips on writing notes and keeping your license safe, sign up for my monthly newsletter (and get access to my free Paperwork Crash Course). I send out extra tips and resources and then you'll never miss another helpful blog post! Happy (and ethical) writing to you!! 

Can't I Just Write Notes on My iPhone?

One of the big things I like to talk about is “de-mystifying the process of documentation.” Every therapist in private practice, and even in most agencies, have a totally different way of writing notes. There’s nothing wrong with that but when we rarely talk about documentation, it becomes a problem. 

You see, this means that as therapists we have little framework for what is best practice. Instead, we figure things out as we go along… and sometimes that means we wait a little longer than we should to seek advice.

A  while back I met a therapist who asked me what I do. After I explained I help therapists create awesome documentation so they have more time with their clients she laughingly asked if she should be doing more than just writing some notes on her iPhone. I've heard about some pretty crazy things, from being months late on documentation to outright and intentional fraud, but this comment took me aback. She was serious!

I told her she needed a file of some sort and should at least document informed consent as soon as possible. She didn't seem to care a whole lot and this shocked me, then made me a little angry. You see, documentation is not some after thought. It is an important piece of the clinical work we do as therapists. 

Aside from the CYA part of documentation (which I do think is very important), your paperwork serves to provide continuity of care as well as a time to reflect on the clinical work you're doing. Much of what we do is ambiguous but if we're not able to put it into words, how are we able to describe the work of therapy to new (or doubting) clients? 

If you're in private practice you have the freedom to decide how and when you want to write notes. A great way to connect the paperwork to your clinical work is to use documentation as a reflective time as well. Consider 1-2 things that stuck out to you about that session and how does it relate to previous sessions? Does this bring up something you'd like to follow up with during the next session? Is there any countertransference or reaction you need to process on your own or through a consultation group?

Write it down, process, follow-up with a colleague or research a topic you may need more knowledge of. This clearly makes documentation a clinical process. I believe this way of writing notes will make you a better therapist and keep you growing professionally. It also makes the act of documentation less of a chore.

If you're interested in more tools to make documentation easier and see how it can make you a better clinician, sign up for my monthly newsletter and the free Private Practice Paperwork Crash Course. And feel free to comment below with any tips you have for making paperwork more relatable!

The Insurance Mole

I have a secret I’m going to confess to the world right now- I was trained as a peer reviewer for insurance companies. That’s right. Those people (commonly known as a care manager or peer reviewer) who call you to talk about why your client needs more sessions.

Don’t hate me!

The truth is, I was trained but then I never got any peer review cases and the job just sort of fell off. So no, I never actually questioned why a therapist hadn’t justified medical necessity or denied sessions to anyone. But through that process and my experience working as a Quality Assurance Manager I’ve learned quite a bit about documenting for insurance.

Contrary to popular belief, insurance isn’t always out to get us and refuse paying for services (not all the time, anyway!). Think of insurance companies as a slightly OCD relative who maintains a very strict schedule and throws a tantrum when you want to make changes to vacation plans on the fly. They like their schedule and they’re sticking to it… unless you give them a good reason not to. 

You see, insurance companies work with millions of customers, so they have a lot of data. They’re able to see the average number of sessions people normally attend to deal with various problems or to work with certain diagnoses. 

They also rely on research. They know what type of treatment is proven to alleviate certain symptoms and what treatments work more quickly or have longer lasting results.  

Insurance companies then use that information to determine medical necessity, essentially,  whether or not a treatment is needed for a specific client, appropriate to the diagnosis/symptoms, and determine it’s effectiveness over time. (To learn more about medical necessity, read this past blog) They have a game plan. And when you sign that form to contract with an insurance company, you agree to play the game.  

So, the big question is whether or not you can all (therapist, client, insurance company) play the game and achieve a win-win-win. My answer is a modest yes… if you play by the rules and learn to woo peer reviewers every once in a while.

First, know the insurance company’s definition of medical necessity. As a peer reviewer, that was the first thing I looked at. Look at how your treatment fits into that definition. Write it out in a simple sentence or two, like a mini treatment plan. If you need more than two sentences, you’re getting too in depth for (most) insurance. Use concise language and be direct.

Second, evaluate the two biggest concerns of every insurance company- cost and effectiveness. Show the insurance company you’re not trying to squeeze every last penny out of them. You just want to do what’s best for your client. When talking with a peer reviewer, identify the progress you’ve already made. This highlights the effectiveness of your treatment. Then identify a clear plan for completing treatment. That may be two weeks or two years from now, but you need to show you’re thinking about the end result.

Ultimately, I was told that if a therapist could explain to me how the services were medically necessary and would help the client, I could recommend they were approved. However, I was only supposed to give a therapist about 15 minutes to do this, ask follow-up questions and make my recommendation, which is why I emphasize learning to be concise. 

Insurance companies feel like big bullies sometimes but remember that when you’re on the phone with a representative, care manager or a peer reviewer you’re just talking to another person. Treat them with respect, listen to their questions, ask them to clarify and know that they are working within the rules of the game as well. And the goal of the game is to get your client the best treatment they need and get them well as soon as possible. Hopefully, that’s something we can all agree on!

Still have questions about documentation and insurance? Check out Barbara Griswold's website. She has a regular newsletter and fantastic resources.

Top 5 Paperwork Resources for Therapists

TOP 5

You became a therapist because you love helping people, not because you love paperwork!

Likewise, I got into quality improvement because I love helping therapists make their paperwork more manageable. Through my years of teaching therapists I’ve acquired a list of places I commonly go for answers, ideas, and inspiration. I’ve compiled five of them that will help you with starting out your practice and getting continued support:

Ethics Codes for Paperwork

While very similar, each discipline has their own ethical requirements for completing and maintaining records. These are basic guidelines for your profession and do not include state laws or HIPAA regulation. I recommend you start here because the principles are easily accessible and brief. Then, seek out laws specific to your state or recommendations from your state’s licensing board or professional association. HIPAA is a whole other deal… I’d encourage you to check out Zur Institute’s online courses specific to HIPAA if you want that information specifically.

Private Practice Paperwork Crash Course

Yes, I’m going to toot my own horn for just a minute. I created a crash course on clinical documentation. In a series of videos sent out over a one week period you’ll learn tips on administrative forms, writing assessments, treatment plans, progress notes and billing to insurance. My goal with this mini course is not to give you forms to copy. Rather, I want to help you gain the mindset and skills to write quality documentation that’s less time-consuming and makes you feel confident for years to come!

The Documentation Sourcebook

This book has a ton of sample forms and a very affordable price tag! It is very detailed but don’t let that scare you. Use the forms as a starting point and pick and choose what you like. They are based mostly on insurance billing so if you have a private pay practice you can overlook a lot of the details.

Private Practice from the Inside Out

Tamara Suttle provides a multitude of practice resources on her website. She has an extensive blog where she frequently highlights experts in specific areas. This includes articles related to client records, HIPAA, insurance and other topics. She’s also super friendly and responds to comments and questions on blog posts with record timing!

Zynnyme’s Insurance Outsourcing Video

If you decide insurance billing is for you then one of the most important things you can do is outsource your billing to an expert. It only takes one problem claim to eat up 10 hours of your time and a large chunk of your profit. Check out this blog interview posted by Kelly and Miranda from Zynnyme where they interview Tiffany, owner of a medical billing company so you can see what it’s all about.

I hope you find these resources helpful. There are lots more out there but I think these are some of the best. What other resources do you use? Leave a comment below so we can continue building our resource lists!

The #1 Reason Therapists Do Paperwork

The #1 REASON

 The best way to have a positive attitude about clinical documentation is to look at the real purpose    behind it. Therapists often hyper focus on certain areas of purpose, such as liability or insurance  reimbursement. However, the real reason we do paperwork is to provide the client’s story.

Every chart tells a story of the client’s work with you. As an objective reader it tells me what you focused  on in treatment, how often you met with the client, and whether or not you followed up with certain  things.

 You spend hours upon hours with your clients doing meaningful work… and it all gets summarized in that little chart in your office (or on your computer).

What happens when you look at the information in that chart? Do you get a sense of the growth that took place? Is it clear how you handled the struggles presented to you? Is it clear that you talked with your client about informed consent and your guidelines regarding confidentiality?

I challenge you to take out 1-2 client charts (bonus points if they’re long-term clients) and look through them cover to cover. Think about things from an outside perspective. Is there anything you read that you find yourself explaining more in your head? Is there anything missing or is it a little too detailed with things you realize don’t relate to treatment (no one needs to know whether or not your client brought their Starbuck’s drink to session)?

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Mostly though, how does reading that chart make you feel? Does it bring out those same feelings that arise if you were to talk about your client? Does it make you feel proud of the progress and things discussed?

My hope is this exercise will help you see what you’re doing well and identify if there’s anything you may need to work on or consult with others about. If that’s the case, feel free to check out my program, Meaningful Documentation Academy.

And if that’s not for you (or even if it is), meet with a colleague so you can share ideas and help one another out. Remember, we are one another’s greatest resource! Happy writing!

The Psychology of Quality Improvement

You’ve probably heard the term “quality improvement” before but do you really know what it means? And what does quality improvement have to do with a private practice? Isn’t that just for big agencies and insurance companies?

I would say no, quality improvement relates to every therapist in every setting. It is often confused with it’s cousin, quality assurance. Quality assurance (in general) focuses on checking to ensure work is completed accurately and is usually a retroactive process.

QI Blog

On the other hand, quality improvement focuses on evaluating the effectiveness of work.This is totally relatable to therapists! As therapists, our work is often very subjective and intangible. It is difficult to describe the specific “outcome” of a particular session. Sometimes, it is difficult to put into words the level of intensity or resolution that occurred during a session. And while a client may feel better, more determined, or more clear after a session, they may have trouble telling a friend or spouse exactly what it is they “got out of” their therapy that day.

We live in a facts-based, results-oriented world. Clients want to know specific results they can expect to see. Family members want to “see change” very quickly (especially if they’re helping to foot the bill). Combine this with our digital era that emphasizes immediate gratification and the situation becomes even more challenging. 

Clients are looking up resources and researching psychological techniques ahead of time. A couple seeking therapy may ask you if you are a Gottman therapist. Another client may be specifically searching for DBT or exposure therapy. The term “archetype” is common language and clients are looking to see if your values match their goals.

Clients want to know treatment is researched, reliable and will give them the results they are seeking.These are the days of questioning long-term research on vaccines. People are not willing to simply “do what my doctor says” without something to back it up and an explanation from a professional they trust.

So, how can we address this in therapy? By using quality improvement techniques, no matter the size or resources in our practice. We can use more than attrition to evaluate a practice… without having to implement lengthy forms or lots of numbers. I recommend using your very own progress notes, assessment/intake forms, and most importantly, your client’s experience!

During your first session, talk with your clients and make note of the things with which they currently struggle. Take time to write those things down, especially in your first couple progress notes. Three months later, bring that up. Are those things still areas of concern? Have they improved and how so? Are these things still the focus of treatment or have you moved on to something else?

In our deep work with clients it is easy to get caught up in the weekly struggles and forget where our clients were just six months before. Quality improvement techniques encourage us to look at whether or not what we’re doing is effective and how we can improve upon it. More importantly, they keep you accountable to actively engaging your clients so they are part of the work and not just you.

You can easily use assessment or intake forms, progress notes and treatment plans to do this. If you have a ratings scale or questionnaire, even better! Pull out that intake questionnaire at week 18 and have your client complete it again. Compare and contrast the results. I guarantee you they will not have the same answers they did during your first session. And even if they did- you’ve now got some serious evaluation to do about why you’ve been working on something for 18 weeks with no subjective progress!

Most importantly, using quality improvement techniques creates buy-in from your clients. They’re able to put into words or onto paper what it is they’re experiencing after working with you. They’re able to focus on growth and see a tangible reward of all their hard work.

If you want to take a step further and implement a regular quality improvement plan as part of your group practice, look into my consultation service. I’ll work with your practice to see what makes sense and ensure you’re clear on how to improve.

Happy writing, everyone!

When I Was a Therapist...

I frequently find myself using a phrase that is somewhat disturbing. What’s more, I’ve decided recently that this phrase is also totally inaccurate. This unassuming yet powerful phrase is: “When I was a therapist…”

WHEN I

I spent a few years providing therapy (e.g. being a typical therapist) and then about three years providing vocational and learning disability assessments through a private company. While my assessment gig wasn’t providing therapy, it was still clearly clinical (and unique enough to get me the occasional impressed eye-brow raise from other therapists). I continued practicing my interview skills on a daily basis and quite frankly, learned how to write reports “like a boss” and in very little time.

However, for quite a few reasons, I needed to find something more stable and full-time. I wasn’t interested in providing long-term therapy again because I prefer the short-term and very focused work. I finally came across a position in quality improvement and thought, “I think I’d like that.” Paperwork had never been difficult for me and I was quite practiced at it, especially in my recent position providing assessment on a daily basis. 

I applied, got the job and it was a great fit! I loved working with other therapists by training them on the county-required paperwork. The documentation requirements for the LA County Department of Mental Health are infamous among mental health professionals here in Southern California and it’s certainly a reason many therapists get out of community mental health as soon as possible. 

However, I found that I could give people great tips on how to capture the data they needed. I was good at interpreting the clinical focus of the paperwork and emphasized this when talking to the therapists I was training. This helped them make a connection to the paperwork and see the real purpose for it. I firmly believe in sharing as much information as possible and that people (especially educated people in a stressful position) are more likely to do well on a task if they understand the purpose behind it. 

So what does this have to do with my saying the phrase, “When I was a therapist…?” While I obviously needed the clinical skill to do my job in quality improvement/quality assurance, I was selling myself short and sending the wrong message to the people I was training. My main goal of training is to show therapists the connection between the clinical work and the paperwork. However, by using that phrase I was essentially saying that I was now a paper-pusher and that meant I could not also be a therapist.

How wrong I was! Do I currently see clients in therapy or for assessment? No, I don’t. I no longer take crisis phone calls and write progress notes. However, I do open my DSM to check diagnoses multiple times a week. I do consult with staff on “tricky” situations and how to bill (or not bill) for their time. I evaluate treatment plans and notice when there are discrepancies in the plan and the actual treatment. I read more progress notes than you can imagine and evaluate whether or not the therapist is providing the appropriate level of treatment.

My work is very clinical and requires not just an MA or PhD in psychology but also practical experience in the field from which to base decisions on. I am a psychologist, a therapist, an assessor, a supervisor, a trainer and I continue to help people on a daily basis. I don’t do this by processing trauma with clients but by helping my fellow therapists make sense of the administrative requirements of their job. I process with them so they can figure out what paperwork is needed, and in turn do the work they love and help their clients. 

I absolutely love helping therapists figure out the messy situations and how documentation plays a role in the treatment they provide. So, sign up here for my newsletter (and free paperwork crash course) and get monthly tips from me or leave me a comment below with a documentation question you have so I can help support you. Happy writing, everyone!

The Mountain of Paperwork in Community Mental Health

Mountain of Paperwork

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

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

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

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

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

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

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

Why Medical Necessity is Important to Private Pay Therapists

Advice Help Support And Tips Signpost Showing Information And Guidance

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

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

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

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