Guest Post by Dr. Maelisa Hall. This is part 1 of a 3 part series on clinical documentation.
There are a lot of things to consider when writing clinical notes but I find that most therapists tend to look at the process from a restricted angle. They think only in the moment about how to write the least possible amount and consider client confidentiality more than anything else. I would encourage you to look at notes from another perspective; look at them as if you were someone else reading them five years from today. Specifically, look at your notes from the perspective of these three people:
The Client – Most therapists don’t consider the fact that their clients may one day ask for their records. There is one key qualifier in that sentence- their records. The records you keep are your client’s property that you safely store. They do not belong solely to you as the therapist and clients can access their records at any time, within reasonable state and federal timeframes. What kind of language do you use when discussing your clients? Is it language you would want someone else to use when writing about you? Are your notes something you would feel embarrassed or nervous to show your current client right now?
A Lawyer – This is probably the person a majority of therapists worry about most. If a lawyer has access to client notes, this likely means some legal battle or investigation is the cause. Regardless of the specific reason, consider what a lawyer who is not on your side would be looking for. She would be looking for holes, times when you got lazy or sloppy and omitted something. She would be looking for vague language that leaves the outcome open to interpretation. She would be looking for inconsistencies that make you seem untrustworthy.
A Colleague – Another key person who may read notes in an investigation is a professional colleague. A lawyer may not consider if a specific action was against your professional ethics code or a contraindicated treatment for a specific disorder/problem but your colleagues certainly will. In my experience conducting peer review sessions with therapists I find that many are quite hard on one another. As a profession, we tend to enjoy analyzing and questioning. Do not expect that just because it is another therapist reading your notes that he will connect the dots you failed to include in your notes. In fact, expect quite the opposite. He will then begin to ask even more questions and your credibility will diminish.
Here are some ways to keep all of the above people happy, as well as ensure you’re acting professionally and ethically:
1. When writing case notes, keep your language free of judgment. If you’d like to add more in-depth analysis for your own sake, consider writing separate process notes.
2. Use a consistent note template and type your notes so they are easy to read.
3. Use client quotes when writing about complicated situations and stick to the facts of the session.
4. Include your clinical rationale for any decisions you make during ethical dilemmas. When in doubt, consult with a colleague and include a brief note about the consultation.
5. Make regular time for your notes so you stay up to date and keep doing the great clinical work you love!
Ready to jump in and read Part 2 of Tips for Writing Notes for Therapists?
Maelisa Hall, PsyD is a clinical psychologist who teaches therapists how to create rock solid documentation so they can spend more time with their clients and less time worrying about paperwork. More info on her upcoming program for helping therapists improve their documentation is available on: https://qaprep.leadpages.net/clinical-documentation-course/