It’s easy to let writing notes slide by thinking I’ll get to it tomorrow or it isn’t that important. However, if you don’t keep up with your notes, you’re doing your clients a disservice. Notes are an important part of private practice. Learn how to write notes quickly and efficiently and why they are so important.
Importance of Writing Notes
How can you keep track of what you did last session or what a client has told you without notes? Nothing can upset a client faster than thinking you aren’t listening because you don’t remember something they told you. You need to be able to keep track of what the client is working on, goals and objectives, homework assignments and progress.
Save yourself some hassle by writing your notes as soon as possible. This way when you give clients homework assignments, you can quickly refer to your note the following week and ask if they completed the assignment. You can check the note before your session so your sessions have continuity. Each session should be a continuation of the last session. The best way to do this is to have accurate and detailed notes to refer to.
Insurance companies require you to write notes and keep updated treatment plans. They want to know that there is a focus to your work and that the client is making some progress. They want to know that you are doing something and that they are getting something for the money they pay you. If you take payments from insurances, they can audit your records. Without proper documentation, you can end up losing your contract with an insurance company.
If you keep good notes, you will be prepared if you get audited by an insurance company, get a subpoena for court or be asked to complete a packet for a disability claim. There’s nothing worse than feeling unprepared when someone requests copies of your notes. Remember, if you’ve reached the point that you are in private practice, everyone will expect a level of professionalism that you must adhere to. This includes having up to date, accurate and detailed notes on every session you have completed.
Structure Time for Writing Notes
The problem in private practice is that you don’t have a direct supervisor who is making sure your notes are complete. You rarely get your charts audited to make sure you are keeping up with your records. This means you have to structure your own time and be sure the notes get done. I have a rule that I don’t leave the office until all my notes for that day are complete. This way I don’t get overwhelmed with having to write a week’s worth of notes in one day. Notes are also easier to write when the session is fresh in your mind anyway.
I try to schedule my clients with enough time in between sessions to write the note immediately after the session. A detailed but simple note is easily written in 10 to 15 minutes. When you get really good at it, you can really write a note in 5 minutes. If you schedule clients with 15 minutes between each session, then you will have plenty of time to write a quick note.
Most of the intake can be completed in session with the client. The first session I spend about an hour going through my intake packet with the client. After they leave, I only have to organize the pages in a chart and write a biopsychsocial assessment with a diagnosis. This can take me an hour so I leave the hour after an intake open in my schedule. This way you get everything done the first day.
Treatment plans can also be completed in session with the client. This way you both know the focus of your sessions. This keeps the client from having one focus and you have another focus. If you complete the treatment plan with them, you will both be on the same page.