Benjamin Franklin is famous for saying that the only certainties in life are death and taxes…and needing to write your progress notes. Okay, maybe he didn’t include that last part, but if he worked in mental health, he surely would have.
Even if you love being a therapist, there is a good chance you don't love clinical documentation. Many of us feel we didn't receive adequate training for this task in graduate school, and it can be a source of self-doubt, anxiety, and procrastination. I recently surveyed a large group of therapists about this topic and found some common areas of angst about documentation that I summarized into three challenges:
Time and organizational constraints; too many competing tasks in the brief time between sessions (phone calls, email, self-care) and then feeling too burned out to write notes at the end of the day.
Uncertainty about what goes in the documentation and fear of insurance audits. This anxiety can lead to avoidance or being overly perfectionistic and writing too much.
Difficulty viewing documentation as a task that enhances clinical work; feeling as if it’s busy work or only there to serve insurance companies.
I’ve certainty done my fair share of grumbling about writing treatment plans and notes and waited with baited breath for the inevitable time my records are audited. In my quest to do a good job, I’ve discovered a key issue. It’s really difficult to find definitive answers on what needs to be in our documentation. For that reason, I want to share what I’ve learned through my workshop, The Happy Therapist’s Guide to Learning to Love your Notes! We’ll talk about the challenges I’ve described in detail. Learn more on the workshop registration site.
As I’ve researched for this course, it’s become clear that to create good records, we need to fundamentally shift how we view this task. Rather than a pesky chore, our notes play a key role in delivering ethical, evidence-based therapy. I’ve come to realize the following:
Treatment plans help me think strategically about my client’s needs, and talking about goals with the client is part of a strong therapeutic alliance.
Progress notes help me bridge to last session - a key part of CBT practice - and help me be intentional in the current session.
Documentation helps me self-review my work and identify clinical concerns. If a note is harder to write, it may indicate I’ve reached a clinical stuck point and change is needed, perhaps more structure in session, different interventions, change of treatment goals, etc.
If you need a cognitive re-frame around your clinical documentation, please consider joining me on December 1st from 9:00-11:30 (mountain time). We’ll break down the three challenges I discussed, engage in reflective and practical exercises, and take a look at templates that can transform your relationship with documentation from angst to ease. I also provide consultation in this area if you prefer an individual, coaching approach.
Please reach out with any questions about the workshop, and feel free to share if you see fit!