One question I receive from a lot of therapists is, “How can I create my own notes template?” But what they’re really asking me is, “How can I make writing notes easier and faster?
The good news is that I can answer all those questions together because yes, creating your own template for writing notes can make things much more efficient. However, my answer is not to provide you with a list of 10 therapy interventions and 10 symptoms to include in a checkbox. I’ve got something even better!
You see, when most counselors want a quick and easy notes form they seek out a template that has lots of checkboxes. This may be through their EHR (electronic health record) or by borrowing one from a book or a colleague. However, most therapists I talk with say this ends up taking them more time because they’re sifting through things that don’t apply to them.
That’s because those checkboxes could be for family therapy, couple therapy, treatment of Schizophrenia, anxiety, and the list goes on. There’s no way you’ll ever find a list from someone else that applies to your clients and your way of doing therapy.
Which leads me to my answer- create your own darn list of checkboxes!
However, let me reign you in a bit here, first. The biggest mistake in this process is trying to create your own checkboxes first in order to save time right off the bat. We’re in a long-term game here. Taking some time initially will save you time in the long run.
Below I have a list of five steps to easily create your own notes template. Notice that if you’ve recently started practicing, this is a six month process. In the long-term, six months really isn’t that long but I know it may not offer the quick answer you wanted. However, this method is practically flawless when followed… because it uses your own words and experience to create a shortcut that is actually meaningful.
Here is my super easy formula for creating your own notes template:
Write your notes in sentence form for at least six months. Use an easy template like DAP (Data, Assessment, Plan) to prompt you and don’t skimp on the info in these notes. If you’ve been in practice for at least six months and already use a similar template, you can skip this step.
- Review your notes for a 6-12 month period. Review every single note for at least five clients. If you’re able to stay focused (keep your eye on the prize!) this should only take about an hour.
- Write down the 5-10 most common interventions you find appearing over and over in your notes.
- Write down the 5-10 most common responses your clients exhibit repeatedly in your notes.
- Identify a templated “Plan” statement for the end of your notes, based on what you typically include.
- Now take the information from #3, 4, and 5… there’s your easy and very personalized template!
Create checkboxes from the 5-10 most common things you write and add those to your existing template. Remember to always include a checkbox with a blank option, so you can write in things that come up as needed. You may also choose to add 1-2 lines underneath the checkbox for a sentence or two as a nice summary for each section.
An example for your interventions section may include checkboxes for “Practiced relaxation exercises,” “Challenged cognitive distortions,” “Reflected on progress made,” “Identified maladaptive relationship patterns,” “Examined current coping skills” and whatever else you’d like to include. Then you would have a blank space for things that come up every once in a while.
One question that often comes up when creating these templates is whether or not you need to include “Assessed for suicidality/homicidality” in every note. My answer is that depends on your client. Is your client depressed with a history of suicide attempts? Then yes, you absolutely should assess suicidality regularly and include that in your notes. But if your client is seeing you for stress at work or social anxiety, it may not be necessary.
The key here is to reflect what actually happens in the room with your clients. So if you are constantly assessing anything, that should be included. And if you’re not, then including it would be a waste of your time and a meaningless action.
The cool thing about this strategy is that it applies to any template, because it is really based on what you do in session. So if you use SOAP, DAP, PAIP or anything else you can do this for each section and save yourself a lot of time. Even if you work in an agency or hospital setting, you can use this strategy to create a helpful cheat sheet for yourself.
If you follow this formula I can almost guarantee you’ll reduce your note writing time but you won’t lose any clinical value.
And although I do recommend a yearly review of all your forms and policies, it’s highly unlikely you’ll need to revise this template often once it’s created. I recommend reviewing your notes with the new template after you’ve been using it for about two months. Make sure it is meeting your needs and adjust if necessary. Then re-evaluate on an annual basis, or if you adjust your modality in any way (i.e. begin seeing couples when you previously only saw individuals or start using a specific method like EMDR, etc.).
If you’re still looking for help getting started with the whole paperwork and note writing process, you can check out my paperwork packet, which does include four notes templates (minus the checkboxes… now you know why!).
Maelisa Hall, Psy.D. specializes in teaching therapists how to connect with their paperwork so it’s more simple and more meaningful. The result? Rock solid documentation every therapist can be proud of! Check out her free online Private Practice Paperwork Crash Course, and get tips on improving your documentation today.