In Consultation


In Consultation

I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task

By Beth Rontal

September/October 2021


Q: I love being a therapist, but I hate writing progress notes and sometimes can’t bring myself to do it. I know it’s risky not to write them. Is there a way to make this task less onerous?

A: Every therapist knows that avoiding progress notes puts their practice in jeopardy. But of the thousands of seasoned and new practitioners who’ve consulted with me about documenting their work, most have asked some variation of your question. They’ll tell me they don’t always know what to write, or they get anxious and resentful and put it off indefinitely. Some hate it so much that they question if they’re even in the right profession. I tell each of them the same thing: yes, you must do it, but there are ways to make the process more pleasant and rewarding. I also assure them they’re not alone in resisting the task. Being a good therapist doesn’t make you good at note writing. It’s a learned skill—one you were likely never taught.

A former professor once told me that grad schools don’t waste time teaching note writing because different practitioners serve different populations and therefore have different documentation needs. Schools assume you’ll learn the particulars of progress notes on the job. This assumption creates a missed educational opportunity and glosses over the reality that specific standards apply to every population.

Given that most therapists who consult with me about their notes have been in practice for more than 20 years, I think it’s this reasoning about on-the-job training that’s the true problem, not the therapist who’s frustrated by the task.

The reality is that documentation is so important that it’s cited as a standard of care in the code of ethics for every mental health profession. We don’t just document in case a client files a complaint against us or we’re audited by an insurance company: note-taking helps us review and revisit our work and has a positive effect on practice. Notes also help with clients’ disability and worker’s comp claims, and they can be used as evidence if a client has a court case of their own.

Even if we don’t contract with insurance plans ourselves, any insurance company that a client bills for our services has the right to see our notes. Plenty of clients have missed out on reimbursement for claims because their therapist’s notes didn’t meet the requirements of their client’s insurance plan. Clearly, that’s not a situation any of us wants.

Notes Have Clinical Value

One benefit of writing your notes in a timely manner is the often overlooked and truly meaningful effect they can have on your clinical work.

When I’m not teaching workshops on progress notes and treatment plans, I see a lot of women clients who struggle with their relationship to food. A few years ago, Kerry, a 42-year-old nurse and mother of three kids under 12, was suffering from depression. She told me that her inner critic was angry with her because she was still binge eating.

We reviewed her treatment plan together, and when she saw the documentation of her weekly visits, she came to realize that though things weren’t perfect, she’d been making real, if gradual, progress all along.

Laid out in the notes were the three months it took her to decide to try an antidepressant, the month it took for the medication to fully kick in, and the two weeks before she was showering regularly. I’d recorded how, as she’d come out of her depression, she’d begun to recognize that she was angry with her loving but demanding husband, and some months later, had begun the difficult process of saying no to his demands and asking him for help, rather than doing all the family caretaking herself.

As she absorbed the notes, Kerry realized the binge-eating part of her was keeping at bay the anger that hadn’t been safe to express as a child. Part of her wanted to express that anger now, which was a valuable insight.

We then made it a habit to review her treatment plan and check the notes every time she got discouraged. It was hard to argue with the commendable progress recorded there in black and white.

Expanding clients’ views in this way is clinically helpful for them, but we therapists also benefit from the documentation process, which can act as a kind of self-supervision. As I write notes, I get the chance to think about what worked, what didn’t and why, and what I need to focus on in the next session.

Legal Protection

Clients need us to take good notes so they can be reliably reimbursed by insurers, but some clients may also call on us one day to share our notes in court.

I’d been working with my client Tina for four years. Her messy divorce and worry for her children meant we spent some of that time preparing her for the emotional impact of testifying before a family court judge. Thinking that her file might get subpoenaed, I wrote every note with confidentiality issues in mind and offered no legal advice in the therapy, since it’s beyond my scope of practice. To document interventions, I used phrases like “Helped client process her emotional response to preparing for the trial”; “Engaged client in guided imagery to help create a calm state of mind in preparation for testifying”; “Reminded client about self-calming skills”; “Identified how anxiety may present during trial, and how to enlist her attorney’s support if she finds herself triggered”; “No legal strategy was discussed.”

Though I was truthful and transparent about the work we did together, I omitted from the progress notes the stories she’d told me about what had happened because they could be subpoenaed. I consider these details confidential information, reserved for the psychotherapy notes. These are the notes that help me remember details from session to session.

Some therapists are surprised to learn that the most common reason our notes are reviewed are board or ethics complaints. Though it’s hard to imagine that clients we work so hard to help would file a complaint against us, it happens. Many clients are in therapy because they struggle with boundaries and have difficulty resolving conflict. It’s important to protect ourselves with documentation in case we become embroiled in that struggle.

During fact finding, what might start out as a complaint about how you treated a client can quickly turn into one about all the information you either neglected to include in your notes, or did include that you shouldn’t have.

This happened to Rashida, a therapist from Illinois, who took one of my courses. A client of hers with a severe history of abuse and neglect had complained of client abandonment. The board threw out the complaint after interviewing the therapist, but it deemed her notes inadequate. To keep her license, she was given 90 days to take a course on documentation and ethics and resubmit her notes for review. Her stress level went through the roof, but her notes were ultimately approved, and she kept her license.

With board complaints in mind, it’s important to document anything out of the ordinary. If a client wants a hug, document that he asked for it, and include whether you gave the hug or not, and how he responded. The same rules apply to a gift. Did you keep it? How did you respond to getting it, and how did the client respond to your response?

Our notes can help us communicate and collaborate with other providers that we might want to consult on challenging cases, and they’ll prove that consultation took place. This can be important if you’re ever sued by a disgruntled client or their family member, or if you’re trying to justify continued treatment to insurers.

The Language of Documentation

Although it can seem that this kind of note taking is going to add hours to our already overtaxed schedules, I assure you, you can write clear, clinically sound notes efficiently. But what should they look like?

Because Cognitive Behavioral Therapy was one of the first modalities to jump on board the insurance train, it set the standard for documentation. It helps that CBT is concrete, measurable, and all about changing behavior. Since change shows up in behavior, insurance companies decided CBT was a perfect match.

This does not mean we all must be CBT experts to keep good records. We can write in the language of any validated technique if the notes are clinically relevant. Just keep in mind that with more than 400 different therapeutic techniques, it’s important not to overdo the jargon specific to the modality. The reviewer shouldn’t need a textbook to understand the changes you want to create and how you intend to accomplish them.

Not only are concrete and easily measurable behaviors such as nightmares, daily crying, and the number of binge-eating episodes relatively easy to measure: so are more amorphous and difficult things, like cognitive distortions, emotional burdens, negative self-concept, and lack of trust. Since the body and the mind are inextricably linked, what we think and how we feel can all be described as behaviors.

From Symptom to Behavior

I like to ask the client two questions that help me—and them—identify what behaviors the client wants to change. I call them externalizing questions.

If a client says something like, “I’m depressed,” I’ll ask, “What does the depression make you do or not do?”

Since many clients aren’t good observers of their own behavior, it’s a good intervention that often provides the first invitation to recognize that the depression is the problem, not them. This can open a flood of observations that relate the behaviors to the symptoms.

Take these answers to my questions about what a symptom makes them do or not do.

Fatigue: “My sleep is horrible; I’m up most of the night tired all the time.” Crying: “I hide in the bathroom or in my car and cry—definitely once a day—but I don’t know why.” Irritability: “I’m angry at my kids all the time and criticizing them nearly every day; it’s a real problem.”

Some people don’t know how they feel and can’t identify what they do. They just know they’re unhappy. For them, I’ll follow with, “If your life was a movie, what would others see you do or not do that would show you were depressed?”

If clients can’t externalize their behavior, the conversation might go like this. Client: “They wouldn’t see anything.” Me: “Really, why not?” Client: “Because I don’t show my business to anyone.” Me: “That’s interesting. Why not?” Client: “I don’t know. People use your shit against you, I guess.”

I might then ask questions to find out about betrayal, trauma, or bullying. Now I have a direction. “Tell me about your friends.” (I’m checking for social isolation.) “Have you experienced people ‘using your shit against you?’” (Checking for bullying and betrayal.) “Do you have a hard time falling asleep, staying asleep, or waking up multiple times a night? How does this affect you?” (I’m asking the client to distinguish between types of sleep problems and their effects.)

Once we take a good history and understand the problem, we can write an individualized treatment plan that will be our basis for the notes to come.

How to Get Notes Done Quickly

My notes take three to seven minutes to write—10 minutes if the session is complicated. No matter how long or short, no one likes to spend time writing their notes. Not even me! And if we can’t get them in after a session, we’re tired by the end of the day and often want to call it quits.

During every documentation course I teach, I ask participants when they write their notes. “Sunday afternoon” is one of the most common answers. I don’t recommend this. Rarely are people able to sit down, pound out 100 minutes of notes, and have the rest of the day to enjoy some much-deserved me time.

The ideal time to write notes is when the content is fresh, right after the session ends. Since that’s not always possible, the next best thing is to finish them at the end of the day. If you can’t, be sure to complete your notes within three days. Three is the magic number for memory retention. Anything more than that and your memory can be called into question in court. If you use an online note program and the date stamp on your note is a full week after the session, an attorney will probably challenge what you remember.

What if you have gaps in your notes? Should you play catch-up or just move on? Though it can seem overwhelming, it’s best to have a note in the file, even if it’s sketchy. Include the basic information needed for billing: date, the start and stop time, the location of the session, the CPT code, and a general description, like “continued to work on progress toward treatment goals.” This is better than nothing. At the end of the note, include the date of the next session to indicate continuity of care, as well as the date the note was written.

What Helps?

You get to choose how to record your notes. Some people use spreadsheets. I use Word docs on a password-protected computer with an encrypted program. Even old-fashioned paper notes locked in a cabinet are okay. Some therapists play music to keep themselves engaged. One therapist I know gives herself three M&M’s after every note. Another hits the gym for a reward.

Even if you find some positive motivation, you may still rather clean the toilet than write your notes. But writing up your good work will save you future heartache and increase your clinical wisdom. A clean toilet can’t compete with that.

***

Beth Rontal, LICSW, founder of the Documentation Wizard, provides training, consultation, and documentation forms and templates. She has a private practice in Boston, MA. Contact: DocumentationWizard.com.

Photo © iStock/Oleksii Didok



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