Therapy is rapidly changing and I think it is such a great thing. We can now offer clients flexibility and increased access to services through online therapy, surveys and outcome measures any time of day, and things like file sharing.
Things have changed a LOT in just the last 10 years. With this switch to increased use of technology, some therapists find it difficult to conceptualize how things may be different from paper. And nothing seems to be more difficult for therapists than maintaining notes.
Yes, if you struggle with notes you are not alone! Many therapists are embarrassed to admit they have had little training in documentation but this experience is extremely common.
Below are six tips for writing notes more easily when you’re doing online therapy. You can actually apply most of these tips to writing notes in any setting, but these will especially ease any awkwardness you may experience when trying something new.
1. View your notes as a story.
The first thing to do is adjust your mindset. Yes, notes are legal documents but they are really just weekly entries in the story of your client’s journey with you. Viewing notes this way helps them to feel more relevant and less scary.
2. Be consistent.
However you write notes, do it consistently. Falling behind in notes is one of the most stressful experiences for therapists. Create a schedule that works for you and schedule in note time that is non-negotiable. Better yet, write most (or all) of your note with the client in session and then you’re done!
3. Use the client’s own words.
Don’t worry about using fancy clinical language in your notes. You want multiple types of people to be able to read your notes and you want the language to be clear and understandable. There is a chance that no one will ever read any of your notes… but there is also a chance your client may read them, a lawyer may read them, another clinical professional, etc. So focus more on capturing what happened than trying to make it sound formal.
4. Set a timer.
If you’re writing notes with your client present, use the last five minutes of your session to wrap things up. That will keep you both focused on clarifying things from the session and creating a plan forward. If you’re writing notes on your own, set a timer for 10 minutes and stick with it.
5. Stay engaged.
Don’t look away when writing notes with clients. It’s important to communicate while completing your notes and explain what you’re doing to avoid a rupture in the therapeutic bond. Of course, you may look away every once in a while, but keep the communication going and clients won’t be bothered by the fact that you’re writing things down.
6. Get client feedback.
When in doubt, ask your clients about things! How do they feel about online sessions, about writing notes together, about reading notes, about filling out surveys midweek, etc. One of the huge benefits of clients having increased access to their files is that they feel empowered and you can more easily stay on the same page and clear up any miscommunication.
Most importantly, remember that practice makes perfect. You (and your client) may need some time to get used to this process and that’s okay.
Take your time to test things out and let clients know you’re doing that. Sometimes, things won’t work out and that may mean it wasn’t a good fit clinically or logistically. Take the feedback for what it is, implement any improvements you can, and keep on doing the excellent work you do.
Over time, you will find that this process becomes easier and things will feel much more natural. You may even find yourself enjoying your notes, while also spending less time on them!
About the Author:
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.