I’m working on notes I didn’t write last week. Sound familiar? I get caught up in tug of war with my notes. Some days, I win! I'm writing my notes carefree in the 10 minutes between one client and the next. Other days, I can hardly construct a sentence and the tasks pile up. I struggle with finding the words to sum up progress and make meaning of sessions. I strive to highlight the strengths and uniqueness of each client and my brain gets tired. My biggest hang-up is imagining a documentation reviewer someday picking apart my work. Whether for a lawyer, an accrediting body, or our own clients, documenting the right stuff is important. We write down what we do to remain accountable.
Most books I've read on the subject of documentation focus on topics like treatment planning and medical necessity. While devising clear treatment goals in documentation is important, I'm not exactly holding a parade about it. Considering the amount of time we devote to documentation, wouldn't it be great to have a re-frame? What if we actually enjoyed documentation?
Let's be real: sometimes notes are just boring and not meaningful. Managed care systems and other regulating bodies insist on making documentation more complicated than necessary. Not all the paperwork we do is client-centered. So far, I've learned the only cure for these plights is to ‘do what you gotta do’ without wasting too much precious brain energy.
We must document sessions even when we feel stuck. While documenting, we may realize when we neglected something important or made a mistake in session. Our documentation can also have potential to cause discomfort for us. I experienced this recently while documenting my work with clients who have trauma histories. Recounting our deepest sessions is emotional work. I might laugh, cry or feel exhausted when doing notes.
What I would like to re-frame is that documentation can shine light on client’s skills, strengths and resources in ways we need to remember. For every documented treatment goal, we can remember our client's words about their aspirations. My hope is that I can look back on my notes and re-discover what I love about my clients and my work. Our documentation has a powerful effect on how we view clients and what we remember about them. We tell our client's stories through our notes. This means they can be interesting! They can have the power to shape our experience of our work! Here are some of my favorite things to keep in mind when writing documentation that inspires me:
- Don't just imagine that your client could read your notes. Try actually sharing or even co-creating documentation with clients. Make treatment plans and session summaries meaningful for both of you. This will encourage you to use client-centered language and talk about your work together. Clients will remember more from sessions and have something to take home if they want.
- Try unconventional formulas. Document with clients using bullet points, home-made charts or graphs. Make a list of all the client's accomplishments in the past week. Show the history of problems on a timeline. This can spark new thinking and feel creative.
- Use quotes as often as possible. Notice the difference between a sentence like 'Client demonstrated insight and motivation toward change' and 'Client said, "I want to be a better dad for my son, I want him to see me sober". Let the client's words document things for you. This way, the client's personality comes alive on the page, giving context.
Do you have creative ways of documenting your work? When do you find yourself inspired about documentation? I would love to hear other ideas and tips from clinicians. Especially for new clinicians, this part of our work can be challenging and daunting. I want to look back at the writing I have done for any client, and be sure that it communicates the respect and honor I have for them and the work we do. We need to find ways of making documentation meaningful and helpful rather than exhausting.
Amy Rosechandler, MS, LMHC is a counselor in Rochester, NY working with teens and adults at a local university counseling center and in her own private practice, Clarity Mental Health Counseling. Amy adores group counseling, youth development, and strengths based approaches to therapy.
Read more about Amy at http://claritymentalhealth.org/about.php