Every therapist is acutely aware that neglecting progress notes jeopardizes their practice. Over the years, I've consulted with numerous seasoned and new practitioners about documenting their work, and a common theme emerges. Anxiety about not knowing what and how much to write, with resentment about the time involved, resulting in procrastination.
This vicious cycle makes cleaning the bathroom more enticing than writing notes. And I get it. Because that’s what I did until I learned the skill.
Some therapists even question if they are in the right profession due to their aversion to this routine task. My response to each of them remains consistent: yes, it's a necessary task, but there are ways to make it more pleasant and rewarding. I reassure them that they are not alone.
Note writing is a learned skill that is often overlooked in our graduate school education. A former professor explained why. It’s assumed that new clinicians will learn on their first job. Because clinics and agencies often work with specific populations with unique documentation needs, each clinic will teach the kind of documentation needed for their population. Though there is some truth to this perspective, it creates a missed educational opportunity. The reality is that there are specific Federal standards that apply universally. The problem lies not with the frustrated and untrained therapist but with the flawed assumption about learning the skill on the job.
Documentation is so important it’s included in every one of our codes of ethics, making clear that even therapists who don’t take insurance, need to document their work to those Federal standards. You can run but not hide.
Good News: Progress Notes Provide Clinical Value
Value for the Client
Often overlooked is the clinical value inherent in note writing. I’ve witnessed firsthand the impact it can have on clinical work. For instance, a client struggling with binge eating found solace in reviewing her treatment plan and progress notes about 9 months into our work. She realized the gradual progress she had made. She was still binge eating but we noticed a reduction in the grip of depression and a greater ability to ask her husband for support. When she recognized that these changes were necessary to address her binge eating, she felt much better. It was hard to argue with the credible progress written right there in black and white.
Value for the Therapist
Therapists also reap benefits from the documentation process as a form of “self-supervision.” The act of note-writing provides an opportunity to reflect on what strategies were effective, identify what interventions didn’t seem to work and understand the underlying reasons. It can guide one’s thoughts on what aspects to prioritize in the upcoming sessions.
Legal Safeguards Through Documentation
Besides the clinical benefits, good documentation can serve as legal protection for both therapists and clients.
I’d been seeing Tina for four years. Amidst her tumultuous divorce and concerns for her children, a substantial portion of our time was dedicated to preparing her for the emotional toll of testifying in front of a family court judge. Anticipating the possibility of a subpoena for her file, that I might not be able to avoid, I consulted with my malpractice insurance to learn how to stay within my scope of practice. I was strongly advised NOT to discuss legal strategy no matter how tempting. Discussing it could have jeopardized both my client’s case and my license.
The documentation of my interventions involved phrases such as “Assisted the client in processing her emotional response to trial preparation,” “Engaged the client in guided imagery to foster a calm state of mind for testifying,” “Reminded the client of self-calming skills,” and “Identified potential anxiety triggers during trial and outlined strategies to seek attorney support if triggered.” I explicitly stated that no legal strategy was discussed.
While maintaining transparency about what we worked on, I purposefully omitted confidential details. This careful exclusion was motivated by the understanding that such information could be subject to subpoena. The details were reserved for my psychotherapy notes. These psychotherapy notes, what I call “memory notes,” help me recall details from one session to the next. Fortunately, my notes were never subpoenaed but I experienced very little anxiety about what and how much to write.
Professional Safeguards Through Documentation
It may come as a surprise to some therapists that there are more board complaints than insurance audits. While it's challenging to fathom, clients whom we diligently strive to help and often grow to deeply care for, might file complaints against us. As with any relationship, even a professional one, misunderstandings and conflict can happen. Many clients seek therapy precisely because they grapple with boundary issues and face challenges dealing with conflict – even with their therapist. A board may follow and the complaint quickly becomes an investigation into one’s clinical file.
A client with a profound history of abuse and neglect filed a complaint against Rashida, a therapist who shared her experience during one of my courses. The complaint was “client abandonment.” Although the board dismissed the complaint after interviewing Rashida, they deemed her notes “insufficient.” They were missing almost all the required information. To maintain her license, she faced a 90-day deadline to take a course on documentation and ethics. For the next six months, she had to submit future notes for evaluation. Her notes were eventually approved, allowing her to retain her license. But the stress took longer to recover from.
Considering the possibility of board complaints, it is important to document any occurrences that may deviate from “the norm.” Though gift giving and touch are traditionally frowned upon in therapy, it’s possible to find oneself faced with the situation. If a client requests a hug, record the request, specifying whether you gave the hug, what kind of hug. (an A-Frame Hug? A pat on the back?) Note the client's reaction. The same protocol applies to gifts—document whether you kept the gift, your response upon receiving or declining it, and the client's reaction to your response. Documenting these kinds of specifics could protect you from a client having a very different interpretation of the experience.
Collaborating with Other Providers
Thorough documentation facilitates communication and collaboration with other healthcare providers, particularly in challenging cases that may require consultation. Case and Collateral Consult Notes serve as evidence that consultations occurred. They are a significant asset in the event of legal challenges from dissatisfied clients or their family members, or when justifying the necessity of continued treatment to insurers.
Efficient Note Taking Strategies
Documentation can be tedious, but it can also be done efficiently without consuming excessive time. As one of the initial therapeutic approaches to embrace insurance practices, Cognitive Behavioral Therapy (CBT) established the benchmark for documentation. CBT's advantage lies in its inherent qualities of being concrete, measurable, and focused on behavioral change. Given that observable change manifests in behavior, insurance companies decided CBT was an ideal choice – because it uses behavioral language to measure change.
However, being adept at Cognitive Behavioral Therapy (CBT) isn't a prerequisite for writing good notes. We can document any validated technique provided the notes are 1) not peppered with so much jargon that they can’t be understood without a textbook and 2) use behavioral language.
Identifying the frequency, intensity, and duration of nightmares, crying, panic attacks, and binge eating are relatively straight forward. But thoughts, feelings, and emotions are also behaviors if we recognize the inseparable connection between the body and the mind. So, the more intangible behaviors such as cognitive distortions, emotional burdens, negative self-concept, and a lack of trust can also be documented using behavioral language.
Insights through Inquiry: From Symptom to Behavior
It’s not difficult to find out how a client’s symptoms show up as behaviors if you know the questions to ask. I call them externalizing questions. If a client says, "I'm depressed," I’ll ask, "What does the depression make you do or not do?"
Given that many clients struggle to observe their own behavior, this externalizing question often provides the first opportunity to recognize that the issue lies with depression, not with the client. A cascade of observations often open up, linking symptoms to behaviors.
Consider these responses to my questions about what the symptoms make the client do or not do:
Fatigue: "My sleep is terrible; I'm awake most of the night and tired all the time." Crying: "I hide in the bathroom or in my car and cry—definitely once a day—but I don't know why." Irritability: "I'm angry at my kids all the time and criticize them nearly every day; it's a real problem."
Some clients struggle to articulate their feelings and can’t pinpoint what they do. They just know that they feel shrouded in unhappiness. In such cases, I might pose the question, "If your life were a movie, what actions would others observe you do or not do that show you are depressed?"
If clients find it challenging to externalize their behavior, the conversation might unfold as follows:
Client: "They wouldn't see anything."
Me: "Really, why not?"
Client: "Because I don't show my business to anyone."
Me: "That's interesting. Why not?"
Client: "I don't know. People use your stuff against you, I guess."
I might then delve into questions about betrayal, trauma, or bullying to gain further insights.
Discussing friendship, "Tell me about your friends" helps assess social isolation. Questions about people 'using your stuff against you' may unveil potential bullying or betrayal. Asking specific and concrete questions like, “Do you have a hard time falling asleep, staying asleep, or waking up multiple times a night? How does this affect you?” encourages the client to distinguish between different types of sleep problems and their effects.
Once a good history is gathered and we understand the problems, we can formulate an individualized treatment plan. This plan serves as the foundation for subsequent notetaking.
Getting Notes Written in a Timely Manner
Writing my notes is a task that typically takes me three to seven minutes, or occasionally, up to 10 minutes if the session is complicated. Despite the varying lengths, no one relishes spending time documenting, not even me! Fatigue sets in by the end of the day. We may have dinner to cook, a child needing attention, a meeting to attend, or we’re don’t feel like thinking anymore! The temptation to call it quits is common. So is getting behind.
In each documentation course I conduct, I inquire about participants' note-writing habits. "Sunday afternoon" emerges as one of the most frequent responses, which is a practice I don’t recommend. It's a rare feat to sit down, churn out a solid 100 minutes of notes, and then leisurely enjoy the rest of the day.
Optimal time to write notes:
The optimal time for note-writing is right after the session ends when the content is still fresh. Recognizing that this is not always feasible, the next best option is to complete the notes at the end of the day. Failing that, it's crucial to wrap them up within three days. Three days is the magic number for memory retention; surpassing this timeframe may cast doubt on your recollection, especially in a legal setting. If you use an online note program and the date stamp indicates a full week after the session, an attorney will likely challenge the accuracy of your memory. It’s not a personal attack. But it will feel like one.
Addressing gaps in your notes can be a daunting task. Should I play catch-up or just move on? As overwhelming as it may seems, it’s best to have some form of documentation in the file, even if it's rudimentary. Include fundamental information for billing purposes: date, start and stop times, session location, CPT code, and a brief description, such as "continued to work on progress toward treatment goals." While far from ideal, it's better than having nothing. Conclude the note by specifying the date of the next session to convey continuity of care. Then add your signature, licensure, and date.
How to Get Notes Done
Choose an approach that helps make the process more manageable. Play music for company. Set a timer. Have a “note writing party” with a colleague. Give yourself small rewards. One therapist I know gives herself 3 M&Ms after each note. Another hits the gym.
Some therapists like using electronic health records. Others still rely on tried-and-true pen and paper notes stored in a locked cabinet. I use Word Docs on a password-protected computer with an encrypted program.
Above all, 1) know the documentation requirements and 2) use a good note template. One that cues you to include all the information you need in a way that you understand.
Even if you’re motivated and know what and how much to write, you may still rather clean the bathroom. But writing up your good work can save you future emotional and financial heartache -- and increase your clinical wisdom. A clean bathroom can’t compete with that.
For a thorough explanation of what and how much to write in your progress notes, treatment plans and the other documentation essential for clinical practice, check out my PESI course, Mental Health Documentation & Medical Necessity: Simple, Clear Guidelines that Maintain Quality of Care and Protect Your Practice
and the Documentation Wizard℠ Clinical Forms.
Plus, you can download these free 25 Tips for Getting Notes Done
for quick completion recommendations from the Documentation Wizard.