Your 2023 Plan to Keep Up With Progress Notes

You know that feeling when you pull up the file of a client you’ve been doing AMAZING work with, only to see that you haven’t done notes in 5, 10, or even 15 sessions? It’s so frustrating. You’re doing exactly what you need to do, your client is having amazing progress, but here you are feeling a pit in your stomach every time you look at their file.

It does NOT need to be this way! Let’s make a plan to get you (and maybe your employees) caught up, feeling confident about what’s IN your documentation and having a plan to make documentation not suck the joy out of your job in 2023! Who’s with me!?

Tips for Writing Professional Progress Notes (and Staying on Top of Them)

Step 1: Find a Little Love for Progress Notes and Documentation

Most of us were NOT trained in how to do progress notes, but we were punished for not doing them properly. Very few people ever explained documentation beyond something that was to Cover Your A** (CYA), to not get in trouble if you got subpoenaed, etc.

It all felt like something you did just so you wouldn’t get in trouble! And usually we weren’t given appropriate levels of time to learn this skill or to actually do the skill. With crazy caseloads and lots of hurting people, we tended to focus on clients first (as we should).

The problem is, once we left these often unsustainable — and sometimes abusive — relationships with employers, supervisors, and documentation, we were on our own. If the only reason you were doing documentation was to keep from getting pulled into a meeting, then it’s SUPER easy to drop this task when you’re in solo practice. And guess what? If you’re a group practice owner who isn’t double-checking your staff’s documentation and whether they complete it, you likely have one (or more) staff members not completing documentation.

So, how do we find a little love for progress notes and documentation? How do we repair this broken relationship? We make it about us and our clients — what it was always supposed to be about! I like to think about progress notes as a love letter to your client(s). What if we died tomorrow and had no time to say goodbye to our clients or make a plan for their future therapy treatment? Your progress notes give them a record of the amazing relationship, their progress, and what’s left for them to do for themself with any future provider.

You’re also keeping a record, a story of their life and their progress from this outside perspective, that’s invaluable. Think about this as if you were remodeling a home. We all love those Pinterest-worthy before-and-afters for how we change spaces. Your progress notes can be those little snapshots of how life used to look, feel, and function.

It’s incredibly easy for clients to get stuck on just focusing on what hasn’t changed and what isn’t working. Taking them back through these snapshots in time can be invaluable to them really taking in their progress and getting the most out of the therapy experience.

If you can make peace with the actual value of documentation, then you can create something that feels worthy of carving out time and energy to come up with a strategy that works. Still struggling to find some love for progress notes? Post in the comments — maybe we can help!

Step 2: Find Some Actual Time to Write Your Progress Notes

Now that you’ve found a little love, let’s get into creating some time to actually do that documentation. I don’t know how many therapists I’ve worked with over the past 15 years that have been behind on progress notes and who also regularly run over on sessions.

Many of us push ourselves to give our clients such amazing outcomes in each and every session. And sometimes, due to being unsure if that’s actually happening, we focus on giving as much time as possible. And, if you have any money issues coming in private practice or any shame related to charging your fee, one way that can show up is in regularly going over session time.

The truth is, if you regularly need more time to do sessions, you need to schedule longer sessions and charge (or bill) accordingly. And you still need to create time to close out the session with documentation.

Are you actually giving yourself dedicated time directly after the session to write or finalize your progress notes? OR do you tell yourself you’ll do them at lunchtime or at the end of the day and then just keep putting them off week after week? When do you start closing your session out? Is it with 60 seconds to go? Or do you start to ground you and your client, check-in, and make a plan for next week with 5 minutes to go?

Have you checked in with clients to see if they prefer a longer session (and then scheduled it), or does the pacing work for them and 45-50 minutes is actually great? That 10-15 minutes might give them what they need to process more fully in their journal, ground in the car, or drive to their next appointment.

While I’ve heard really awesome trainers recommend having a day at the end of the week where you do all of your progress notes, I strongly feel therapists should do progress notes at the close of sessions whenever possible. Why? Because it’s a way of closing out the experience for YOU as the clinician. It’s a way to download and untether from that session and then free your energy up for your next client. It also takes WAY less time when the session is fresh in your mind than if you have to recall it and go back to that experience.

And finally, from a legal or ethical perspective, they give more weight and trust to notes that are done at time of service than notes that are done hours, days, or weeks after.

Step 3: Create a Progress Notes Template and Process that Works for You

Let me be clear… when I say progress notes template, I don’t necessarily mean a bunch of checkboxes or a standard note you copy and paste for every session. But you do need a way of conceptualizing your sessions and writing notes that works for your brain and the type of clinical work you do. An EMDR therapist can have a very different process than a psychodynamic therapist, and they’re both different than a CBT therapist, and that’s all okay.

Just because your notes look different, that does NOT mean they’re wrong. And, frustratingly enough, you could do your notes exactly like someone else and that doesn’t necessarily mean they’re right either. You need notes that are useful to you and your clients, and that will get you and your client’s needs met (we’ll talk a little bit more about this in Step 5).

For right now, though, starting with any process to see if it works well for you is better than no process at all. Taking any notes is better than taking no notes. Yes, I said it!

So, if that means you’re writing with an iPencil on an iPad and that converts into text in your client’s health record, that works. If that means you write it on paper, take a picture, and upload it as an electronic health record, that works. If that means you write it on paper, take a picture that converts it to type (isn’t technology great), and paste that into your client’s electronic health record, that works too! The key is to start doing something and getting into a rhythm and give yourself room and space to explore what does and doesn’t work for you.

Step 4: Create a Progress Notes Routine

You may think you need to focus first on catching up on your progress notes… but you don’t! Focus first on creating a progress notes routine where you’re regularly doing them after the session for all sessions you do in a day and a week. Once you have that routine or habit in place, it actually makes sense to work on the “catch-up” part of things. I wouldn’t worry about being perfect with progress notes during this initial routine-building. Just focus on ending your sessions on time. Take notes in under 5 minutes (set a timer), and let it be good enough for now. That will always be better than not doing them!

Step 5: Make a Plan for Catching up on Progress Notes

Now that you’re in the rhythm, you can schedule a day to work on catching up with current clients scheduled. Celebrate EVERY single file you complete. Stop and do a dance party, put on your favorite music, or maybe have a piece of dark chocolate after each one. You get to decide what works for you. Remember, this plan for catching up can’t get in the way of your progress notes routine and getting all current sessions done in a timely manner.

Step 6: Review Your Process and Uplevel Regularly

Finally, once you’ve caught up and you’re in a routine and rhythm, now’s the time to start working on the content of your documentation and progress notes. Now, you can start working on making sure your progress notes will meet the need for medical necessity or pass an insurance review if you take insurance payments regularly, etc.

Give yourself time to learn these skills. We have a free training on what goes into great documentation and includes templates We have a free training on what goes into great documentation and includes templates here.

Are you ready to make a commitment to having a healthy, happy relationship with documentation in 2023? Post below and share your plan for never getting behind on progress notes ever again. We pinky-promise you’re not alone and there are strategies you can use that’ll work for you. You just need some time and support in finding them!