Clinical documentation can be an anxiety-provoking topic for therapists because it may seem like there is conflicting information about what is needed and there are so many different approaches to this element of our work. When therapists do not feel confident about their approach to clinical documentation it leads to working inefficiently because of overwhelm + overthinking. The tips shared in this post are intended to help therapists take inventory and find an approach to clinical documentation that is do-able and sustainable for them.
Take Inventory of Your Clinical Documentation
Begin by taking inventory of your current documentation practices by asking yourself what documentation you are keeping and why. The information gained from completing the inventory can give you insight in terms of how to move forward in making adjustments to your documentation processes.
Two things tend to happen through this inventory process; either therapists realize they are doing way too much and have no reason for it or they realize there are gaps in their documentation that are contributing to their anxiety.
If you are struggling with the “why” part of this question, I suggest that you consider ethical standards/best practices for your license, insurance company requirements (if applicable), the needs of your clients and your own needs as a therapist. There are several links at the end of this post that may be helpful to you in gathering more information, if needed.
Additionally, as you take inventory of your current documentation processes you want to ask yourself what is working and what is not working about the way you are currently approaching documentation. Where are you getting stuck and spending more time than you’d like?
The inventory process is also a time to identify
and begin to work through mental blocks and
other barriers related to documentation.
Create Systems to Support Your Clinical Documentation
Therapists who keep up with their documentation have strong systems supporting them in doing so.
One element of a solid system is having dedicated time to work on notes each week and sticking to it.
Do you write your notes during your sessions? Immediately after the session? Batch them?
It does not matter which you choose as long as it resonates with your approach to work and you will follow through! You may need to experiment to find the best fit for you.
I personally like to batch my notes. I see a few clients and then block off an hour to write those notes, do other administrative tasks and hopefully take a break before seeing more clients. Batching notes allows me to be more efficient in writing my notes because I get into a groove of concisely recording the important elements of my sessions. In order to stay caught up while using a batching approach, I have time blocked off on my schedule to work on these notes and hold boundaries around that time.
Templates can also help therapists more efficiently write notes because they streamline our process and allow us to avoid over-thinking. You likely don’t have to start from scratch; your electronic health records system may have templates you could use or adapt. You may also want to create your own database of preferred wording for notes and treatment goals, especially when you come up with phrasing you really like.
Approaching Documentation Backlog
The therapists that I speak with who have a backlog of notes to write are often very discouraged. It is hard for them to see the light at the end of the tunnel because it feels like they are getting more and more behind.
I recommend a two-pronged approach to backlog.
- Create and implement a system that works to stay current with each week’s notes while working on the backlog notes so that you aren’t creating more backlog each week.
- Carve out time to focus on current notes each week + separate time to work on the backlog notes. Time yourself writing notes, so you know how much time it takes you to write an average note and can accurately determine how much time you need to devote to notes each week.
- Establish realistic goals for yourself regarding how many backlog notes you will work on each week so you can celebrate progress + build momentum.
Experimenting to find an approach to clinical documentation that works for you and pairing that with solid systems to support you will allow you to feel more confident in navigating your documentation with more ease.
If you need support in refining your approach to clinical documentation or developing a plan of attack to tackle your notes backlog, I’d be happy to help. Claim a complementary 20-minute Clarity Call here.
Take Care,
Sarah
Additional reading:
Therapy Notes FAQ (QA Prep)
How to take Clinical Notes (series of blog posts written by Tamara Suttle)
Detailed or lean therapy records? (APA)
Tips for shortening your notes
Suicidal Ideation: How to Document
Writing Progress Notes During Sessions: Why it helps and the big mistake to avoid
I am so glad that I found your website. I’ve had my own practice for almost 6 years and have been to the hospital twice in the past 2 years because I am SO overwhelmed it is impacting my health. I love being a therapist, and my disorganization and challenge with boundaries MUST change!
Hi Dawn, It is not uncommon for therapists to fall behind when facing challenges as you have in the past two years. Know that you can move to a place of more ease. In addition to the blog and other resources you’ve found on my site, I’d be happy to talk with you about a specific strategy that could work for you to dig out of overwhelm. Please email me at sarah@sarahleitschuhcounseling.com if you’d like to set up a complimentary 20-minute Vibrant Therapist Clarity call to come up with a personalized strategy.