A guest post from Dr. Maelisa Hall, of Q & A Prep!
Lots of therapists experience a special type of “writer’s block” when sitting down to write case notes. And if it’s been a long day, this may be the last thing you want to do.
I find this often creates a nasty habit of putting notes off for too long or writing just a couple sentences and completely disconnecting from the paperwork altogether. This can then lead to writing notes late at night when you’re exhausted, or even worse, ignoring notes altogether until you’re behind by days or weeks.
One strategy I like to recommend is connecting the notes to your clinical work so they have more meaning and in turn, become more enjoyable.
You can do this by:
Writing notes only during times when you are calm and not feeling overwhelmed or rushed.
Using a regular note template that takes the guesswork out of how to format your weekly notes and lets you focus on clinical content.
And by using regular questions, or prompts, to ensure you focus on the essentials.
Since #3 is easy to implement right away, let’s focus on that! Below I’ve outlined four simple questions you can ask yourself each time you sit down to write notes. These will help you keep your work on task and connected to the clinical meaning of your documentation.
Am I ready to do this?
Yes, this also relates to #1 above and this is the first question to ask yourself every time you write notes. If you are feeling stressed or rushed, this is not the time to write notes! Documentation is part of your clinical work and allowing sufficient time to write notes is essential to your success as a counselor in private practice.
Make sure you have time scheduled each week that is dedicated solely to documentation. This will help take some of the pressure off. Then, when you do sit down to write your notes, check in with yourself. Notice any tension, resentment or anxiety and address that rather than simply jumping into the task.
I recommend counselors take about five minutes to find a calm space and reflect on their sessions. That way you get into the part of your work you love best- the focus on your clients. Now use that as your motivation moving forward with your notes.
What was the general theme of our session?
Now that you’ve got your head in the game, focus on the essentials. Reflect on what transpired and identify a general theme for the session. The outlying information doesn’t need to go in your note.
Keep things simple and just write 2-3 sentences about what transpired. If you’re having difficulty keeping to a shorter note then first start by writing more and paring it down afterward. Are there any off-topic sentences you can remove?
For those who tend to write more, this will take practice. That’s okay, just keep at it, write, pare down, etc. You’ll start to catch yourself writing things that are unnecessary as time goes on and your notes will become more concise and more simple to complete.
What would my client think if they were looking over my shoulder?
Once your note is complete (usually after 5-10 minutes) then look over it and make sure the language used is appropriate. One easy test for this is to think of your client actually reading your note. Identify if there is anything in the note that could be potentially harmful or offensive in some way and remove it if needed.
Does this chapter of the story make sense?
This last question relates to treatment planning and looking at your note as one piece of a larger puzzle. Did you remain “on course” and does today’s note flow well with other notes related to this client?
If not, you may find that you’re steering off-track treatment wise or that your notes aren’t capturing what is really happening in sessions. With some clients, it is easy to get caught up in weekly “drama” so looking at your note as part of a bigger picture helps conceptualize where you’re going and what steps to take next.
This can also help you to see places where you’re stuck. Perhaps you realize you’ve reviewed the same things over and over or notice you have neglected to follow up on something. Make sure every note has a flow that works together with what’s really going on for your clients.
With all these tips and things to ask yourself, you should always be able to push through that writer’s block with your client notes! And now you have a way to connect your clinical work to the paperwork you complete, so it’s not so dull, either.
Maelisa Hall, Psy.D. specializes in teaching therapists how to connect with their paperwork so it’s more simple and more meaningful. The result? Rock solid documentation every therapist can be proud of! Check out her free online Private Practice Paperwork Crash Course, and get tips on improving your documentation today.