Progress Notes Made Easy
DISCLAIMER: This post is for general information only and is compiled based on my experience in multiple treatment settings. Your employer/organization's documentation requirements will supersede anything mentioned here.
In general, documentation seems to be the bane of every clinicians existence. Most of us love what we do in terms of working with people and holding space for them to work through the issues with which they present, but absolutely loathe the time consuming process of documentation. In my experience, progress notes are the number one area in which clinicians get tripped up and fall behind.
Photo by Brooke Cagle on Unsplash
Of course documenting what we do with clients is imperative to ensure accountability and give a record of our activities, but what seems to be the trouble is the overwhelming and arbitrary amount of documentation that mounts due to the "requirements" of managed care providers. Unfortunately, this is the system in which we operate and I hope to make this process a little easier and more efficient...at least for now.
Here are some helpful tips to ensure progress notes don't become a giant weight that holds you back.
Select Your Note Type
There's more than one way to write a note, so experiment with different types. The two most common are DAP and SOAP notes, which are very likely recommended by most agencies and clinics. I, personally, use the DAP note — data, assessment, plan — because it streamlines the note and keeps it simple.
SOAP notes — subjective, objective, assessment, plan — are another way to write your notes that breaks down the data into two separate sections. Some people simply use a note that is a series of check boxes, while others have the luxury of making up a hybrid. Either type is fine and perfectly acceptable. Play around with these and go with what feel right or most efficient for you.
Keep It Simple
Your notes do not have to be a word for word account of what happened in the session, not even the topics you discussed. Keep it simple by sticking to the facts and keep it brief by limiting what you say in each section to 2-3 sentences. Speak to the themes you noticed and the interventions you used — use the Golden Thread to weave it all together.
Time Management
A proper progress note should take no more than 5 or 10 minutes to complete. If you think about it, the standard 50 minute therapy session was designed as such to allow for documentation during the last 10 minutes of the hour, that way you got paid for documentation and the session. Yeah, but tell that to insurance companies who only pay for up to 60 face-to-face minutes. *eye roll*
But I digress.
Most of us don't use the time between sessions to document, but instead use it to attend to bodily needs (go to the bathroom, feed yourself, walk around/stretch, etc, etc) as we should, but this is still a good rule of thumb. You are including too much if it takes any longer than five to ten minutes per note.
Work Smarter, Not Harder
If your notes follow the same general pattern and use the same general phrases, you can save a ton of time by creating a template or use hot keys/shorthand keys/macros. Many EHRs nowadays allow template customization and/or have a "copy last note" function that pre-fills your note...USE THEM! This way all you just have to make changes relevant to your most current session without reinventing the wheel each time.
Process, Not Content
Progress notes are not about all the topics discussed throughout the session, but simply the larger process.
For example, no one needs to know that your client's best friend's sister was in a car accident at the corner of Lake and 17th Ave. She was driving a red Kia Sportage that reminded your client of the car they used to drive in high school, which brought back memories of the car accident your client was in while attending college at Stanford in 2013.
Too much detail, no one cares!
Instead, speak to the themes that came up and how they relate to the overall treatment goals -- the Golden Thread. Simply state, "Client reported trauma symptoms (re)emerged in response to an acquaintance's accident this week. [Then, note interventions used in session]" That’s it, that’s all it has to be!
Good Enough
Finally, if it's taking too long to write your notes, just do a "good enough" note. If you can't remember details because you got three weeks behind and have a hard time connecting dots, that's okay...just get it done. In the grand scheme of things, one crappy note (or a few) is likely not going to be the thing that triggers a clawback or any sort of significant consequences. Being caught up is preferable to perfect notes.
In summary, progress notes do not have to be the bane of your existence; ideally, a full days worth can get done within an hour. If you're struggling with keeping up, please bring it up in supervision to get help brainstorming strategies to stay on top of your paperwork. Zero judgement here because I've been there too. Bottom line, we need good clinicians like you in the field, but it won't happen if you're burnt out due to something as minor as paperwork.
Happy documenting!
If you have other strategies that have helped you with note taking, share them in the comments below!