Guest Post by Dr. Maelisa Hall. This is part 2 of a 3 part series on clinical documentation.
There is one phrase every therapist needs to ask before, during, and after writing clinical case notes: “Could another therapist read this and know my actions were appropriate?” You’re a professional and you’re held to specific standards. If any case were investigated for some reason, the general rule by which you’ll be scrutinized is whether or not your professional peers would have acted in a similar way given the same circumstances. This is referred to as the “standard of care.”
The first thing therapists usually think about when writing anything is confidentiality. We’re trained to make this one of our top priorities, if not the top priority. However, that does not give us an excuse to leave out important information in our documentation. I’m not saying you need to transcribe your sessions but I am saying you need to provide enough information for an objective person (at least, an objective therapist) to understand your client’s state of mind and your reasoning for actions related to that. Remember, psychotherapy progress notes are very privileged information. In the rare circumstance someone is actually reading them, you don’t want any doubt regarding whether or not you provided the best service for your client.
Working in quality assurance, I cannot tell you how many times I’ve had to ask therapists to explain situations because I couldn’t tell what had really happened from the clinical progress notes. Their explanation usually made sense but the missing component was that they never wrote any of those important things down.
What if it were two years later and I asked the therapist? Would they remember enough to explain the situation to me so that it made sense? Would you remember all the details of one specific case years later? Maybe, but likely not. And even if you did remember all the details, how can I trust that you really do remember everything accurately? Lastly, what if you remember something different from the other party?
Without clear documentation the person who loses out in every scenario is the therapist, hands down. We are the professionals and it is our duty to ensure our actions are ethical. It’s also our duty to prove we acted ethically.
Whenever you have a question about treatment or encounter an unusual situation, follow two clear steps.
1. Consult with a trusted colleague (or even two!) about the situation.
2. Clearly document your consultation. Write down your process and rationale in a case note so it’s clear you weighed the options and made an informed decision. Don’t worry about your writing style or using specific formats, just make sure you write the necessary information and date it.
Think about explaining your decision to another professional and write it out. Use that same idea even for your regular notes. If you had to briefly explain to a colleague what happened in your session yesterday, what would you say? The main components should always be what you did and how the client responded.
Still a little uncomfortable with how that should look? Have no fear, samples are coming! In part three of this series I’m going to give you four potential templates you can use for notes with any client in any practice and give a sample for each.
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/