In psychotherapy, notes are called differently: progress notes, therapy notes, psychotherapy notes. You can choose any synonym you like, but the idea stays the same: note-taking is a vital part of a session progress helping a provider to structure a patient’s data.
Whether to record something directly at the session is a personal matter for every practicing psychologist. You can use a dictaphone, simple paper notes, or a PMS.
Psychologists working in a team (or an institution) simply have to keep such records in case of a replacement or supervision.
Moreover, we believe that a psychologist working individually also needs to keep records of the client's case. Let it be during or after the session, but make sure you comprehensively fill in all the obtained information and changes.
This article will help you to learn about:
- Why to keep counseling notes
- What to include inside the notes
- Different modalities of notes with examples
- Benefits of electronic health records.
Scroll down and let’s get started!
Why Do You Need to Keep Records?
Notes are designed to perform various functions, including keeping track of patient progress and regression, making alternations to the current treatment plan, and containing billing information. They are necessary if we talk about a clinician with a big list of patients and a waiting list.
There are some additional reasons to keep session notes. They include:
- Help with a leaky memory. For example, it is somehow inconvenient for a professional to ask the client, "What kind of homework did you have?" You can, of course, pretend that this is such a special provocative question, but why?
- Planning for the future. Sometimes at a session (or later) the thought arises that it would be necessary to include this or that exercise/medicine/question to the plan. Where else to write these things down so that they can be found later?
- If you attend a supervision-intervention, or transfer clients to another therapist, then such records are very much in demand.
At Medesk, information about each patient is stored in an individual electronic medical record. It allows you to view all the services rendered to him during the treatment at the clinic. The attending physician can get acquainted with the patient's medical history, view all the appointments and reports that were written by other doctors, as well as compare the results of current and previous analyses of the patient.Open the description >>
You see, it is impossible to imagine a meaningful counseling session without written relevant information.
What Should You Include Inside Therapy Notes?
Let’s divide therapy progress notes according to the type of session, whether it’s a first appointment, or a follow-up visit.
#1. Things to write down at the first session
When you see your client for the first time, your attention should be focused on:
- Client acquisition (recommendations, found on the internet, via social media etc.). Client acquisition is a core channel of receiving potential clients, so we strongly recommend not ignoring it.
- Request, goals, and expectations. The first therapy session provides you with subjective information about the client's condition. This information is better to be written down as a direct quote.
- Disturbing symptoms. It's imperative to emphasize that it's an integral part of the treatment plan and future sessions.
- Biographical information (born/married). As part of a group therapy, this information will be useful for creating the appropriate patient groups.
- Medical history, medication intake, previous experience of psychotherapy, the inner picture of his mental health condition and its causes.
- Your assumptions about typical trigger situations, automatic thoughts and beliefs, if any, surfaced at the start.
- Intervention session (in a feedback form, handouts as homework, and a well-being check at the end).
As you can see, the major task of the first visit is collecting the maximum information about a client, creating (at least approximately) a future plan of treatment and choosing an appropriate form of note-taking for this very situation.
#2. Process notes of a follow-up visit
You've taken a first look at a person, learned about his background and symptoms. The next step is a follow-up appointment where it would be prudent to note:
- Changes in well-being, thoughts and behavior since the last session.
- It is also interventions at the session that make up the agenda. It’s handy for making alternations in a treatment plan, if needed.
- Detected automatic thoughts, beliefs, trigger situations.
- Homework with the probability of completion.
- Plans and ideas for work next time.
- The client's well-being / feedback at the end of the session.
At the Medesk medical information system, you can create any report templates that make it easier for the doctor to fill out the card and allow him to devote more time to the patient.Learn more >>
Taking all of this information into consideration will contribute to the high quality of your own notes. We have made a compilation of the most common types of notes for your convenience.
Different Modalities of Notes with Examples
There are many types of note-taking in counseling depending on the treatment goals, the patient's condition, type of illness and other factors. Anyway, it's up to the specialist to choose the type of records, especially if we’re talking about a private practice.
We’re here to give you a hand on the most common and workable, not to say, effective and easily applied note templates and examples.
#1. SOAP notes
SOAP stands for Subjective, Objective, Assessment, and Plan. The essence and goals of this type of progress recording are determined by four essential elements.
The idea is to be subjective at the beginning, meaning focusing on the patient’s words and information given, while ignoring your own interpretations and views as a professional.
After that, you turn to objective data. Your task now is to write down any observations concerning a patient's symptoms, complaints, and mental state.
The assessment stage combines subjective and objective components. The task is to interpret the professional information received during the session.
And finally, you as a provider make plans for the next sessions. Try to set achievable goals, split them into smaller ones, because they make a client feel better and lead to a faster recovery.
#2. PAIP notes
PAIP stands for Problem, Assessment, Intervention, and Plan. Let's look at these stages in more detail.
The first step is to determine the problem. Listed below are a few examples of problems to write down:
- A client can’t sleep at night
- He feels depressed after the death of his relative
- A married couple has decided to divorce and so on.
The assessment is your professional analysis, which you already know. Here you give your own reasoning on a problem, for instance:
“A client is feeling guilty after the death of his mother because, in his opinion, he did not pay enough attention to her. According to the patient, he spent the whole weekend with her. Apparently, there is a complete absence of separation and the maternal complex of the deceased.“
As for intervention, here you should answer the question ”What did I do at the session?”
For example, it’s prudent to document your recommendations, techniques used and a client’s reactions to your methods:
“An empty chair was placed in front of the client. The therapist instructed the client to imagine someone sitting on him (including himself), and then started talking to his "interlocutor" using speech or gestures. Traumatic childhood memory for further clarity.”
The planning stage is almost the same for every note-taking process. In this section, you set goals and tasks for the next session.
#3. DA(R)P notes
DARP, or DAP stands for Data, Assessment/Response, and Plan.
The data section is very similar to the subjective and objective parts of SOAP notes. It includes all relevant information about a client’s behavior, responses, reactions and state at the session.
An assessment/response is a recording of a client's response to your professional assessment, in other words, the results of the session are shared with the client.
The plan section doesn‘t change from type to type of the notes.
#4. BIRP notes
BIRP stands for Behavior, Interventions, Response, and Plan.
First, during the behavior stage, it’s better to learn more about the client experience. The questions to ask:
- Have you been to psychologists before?
- Do you know anything about our work here? Are there any expectations?
- What are the requests?
If a person has previously been with your colleague, then at this stage you can get a lot of information about the client. People often switch psychologists after the fourth consultation and start looking for a new one. Perhaps the client will give some recommendations based on past experience.
Second, the interventions. All your methods and techniques must be stated here, providing the needed information for the next stage of response. Like in previous note types, a patient's response to the therapy is analysed and recorded.
Finally, the plan section provides details about the alternations to the treatment plan.
Obviously, there are a lot of types of mental progress notes that can meet the demand of every private practice professional. But using electronic health records is the correct strategic decision.
Benefits of Electronic Health Records
Electronic health records, or EHR, can make your note-taking process much more convenient and secure. If you are a private practitioner with no employees, manual writing can devour a significant part of your workflow, reducing face-to-face hours with patients. Needless to say, paperwork is a tiring process.
But by means of EHR you can gain a number of benefits, including:
- The data can never be lost
- All information about a patient in one place
- A large amount of pre-set templates and forms that can be altered to suit your practice’s requirements
- The autofill option makes it possible to fill out the forms during a session
- You can easily automate your referral letters, invoices, billing, receipts and consent forms!
Regardless of the forms and means of writing counseling session notes, you should always keep in mind that a client’s progress is the goal to be achieved. And if you are looking for a faster and more efficient way to focus on your client‘s mental healthcare, Medesk is everything you need.