One of the most common questions I get from other therapists hoping to simplify their documentation is How can I make my notes shorter?
Many counselors in a private practice setting want to keep good case notes but they are unsure what is actually needed in their notes to meet ethical standards. To avoid missing something crucial they will often add unnecessary details.
To complicate matters, many of us were trained in community mental health settings where documentation is very specific and often does require a certain level of detail to meet third party requirements. However, we receive little guidance on what the gold standard in a private practice would include.
There are many things you want to include in every session note but most of it is record-keeping rather than clinical information. For example, client name and date of the session should always be included in every note (and Im sure you were aware of those requirements already).
Clinical content is much more ambiguous and difficult to outline. As a trainer in quality improvement, I find myself answering most questions with it depends… which greatly frustrates some therapists. However, once you are able to master a general mindset of note writing the task really does become much more simple.
Thats why Ive included seven tips below that help you change your mindset about writing notes. With each exercise youre able to identify what is clinically important and then shorten your notes accordingly all without missing out on quality.
- Think of a theme for each session. What was the main focus of that session? Stick only to that. The rest of the information is likely irrelevant. To simplify, ask yourself Was this central to our treatment plan? Did this lead to a specific insight or breakthrough? Was there something I explained in detail or taught my client? Focus on those key things. The minor details arent necessary.
- Use a template and stick to two to three sentences in each section. I recommend DAP (Data, Assessment, Plan) because it is simple but covers all the clinical bases. Unless something extraordinary happened in your session, two to three sentences in each section of the template should provide an excellent clinical note.
- Set a timer for 10 minutes and then begin writing your note. If you werent able to finish one case note in that timeframe, identify where your time is spent so you can begin shortening that timeframe. If youre already at 10 minutes or less then you may be just fine. Realistically, you should plan to spend five to 10 minutes writing notes for a 45-minute session. Less time than that and youre likely not reflecting enough on the clinical content.
- Do a review of your notes and identify what was nonessential and could be taken out. Choose one client file and read through six months of notes. Youll likely notice themes of things that stand out as nonessential. Take note of those so you can avoid them in the future. And since youre already doing a review, I also recommend you identify things that may be missing or need improvement. This can easily be done in about 30-60 minutes.
- Review six to 12 months of notes and identify common interventions to create check boxes. This step is a more long-term plan for shortening notes but can be very effective when done thoughtfully. I never recommend copying checkboxes from a pre-made template or from another therapist because they are likely to have a different style than you. Instead, use your own notes to pull out the things you write over and over across sessions and clients. Then put five to 10 common phrases into a checkbox and include one or two lines underneath to capture any other information. You could potentially do this action for each section in your template.
- Meet with a colleague or supervisor to do a mutual chart review. This suggestion is an excellent way to get feedback and also resolve anxiety around whether or not your notes are good enough. Choose a respected colleague and give one another tips as well as constructive feedback on what could be improved.
- Bring up a session in your next consultation group and write a note together as a group. Every time I have therapists do this exercise in a training they find it extremely helpful. Either have someone describe a session, enact a mock session or watch a video (the Gloria videos are great and readily available on YouTube) and then spend five to 10 minutes having everyone write a note for the session. Share your notes together and compare and contrast.
Not only can writing notes be more simple, it can also be interactive and fun when you use some of these techniques. The key is putting yourself in a mindset of clinical growth rather than resentment or dread.
Comment below and let us know which of these strategies you found to be most helpful!
Therapy session photo available from Shutterstock