As a psychotherapist, each encounter you have with a client must be documented as a progress note. If you fall behind on notes, your list of notes to complete continues to pile up as you continue seeing clients. Without a sustainable strategy for staying on top of progress notes, this cycle can quickly get overwhelming and contribute to burnout.
You don’t have to stay stuck in a cycle of never-ending catch-up. Here are 3 tips for keeping up with progress notes:
1. Schedule time for notes on your calendar
For therapists, documentation is a part of the gig. So it makes sense that you would complete this component of your job during “work hours”.
Saving your notes for your day off or late at night may work well enough for some, but it may also make you susceptible to resentment toward this part of your job if it’s cutting into your time for leisure or fun.
Some therapists may choose to complete their notes at the end of each workday, or block out time at the beginning of each day to complete the previous day’s notes. Others may block time after each session to complete the progress note from that session. Some might prefer to complete all their notes from the week on a designated day. Either way, by scheduling in time for notes on your calendar, you’re protecting that time to get your notes done on your terms instead of scrambling later on to find time to complete them.
2. Start a draft of each note during or immediately following each session
Even if you have a great memory, the details of your session are going to slip away the longer you wait after your session to complete the progress note.
If you see clients back-to-back, you may not have time to complete the note for each session right away, which is why it can be extremely helpful to jot down key words or themes along with your client’s mood, affect, symptoms, presentation, etc. When you come back to your note to complete it later, you’ll have cues to spark your memory of what you worked on to complete the note.
Some therapists may choose to take notes during the session with pen and paper and then transfer their notes to their clients’ electronic file. Others may keep their clients’ e-files open during the session and take notes directly into the progress note draft. Either way, being explicit with your clients that you are taking notes can help to build trust and strengthen the therapeutic relationship.
3. Simplify the process
Subscribing to an electronic health record (EHR) software, or joining a group practice that offers access to one, can make the process of record-keeping much simpler and more efficient than coming up with your own documentation system. EHRs often make use of auto-fill features and drop-down menus, which can help to significantly cut down on the time it takes to complete each note.
Beyond that, remember that only essential themes are necessary when it comes to note-keeping. If it’s taking you longer than about 10 minutes to complete a progress note, it’s possible you may be including non-essential information which could be making it more difficult to complete your notes efficiently.
If you tend to include lots of detail in your notes for your memory’s sake, consider keeping separate process notes which are unofficial documents and thus allow you the freedom to jot down ideas and thoughts without polishing them up, cutting down on the total time you spend on documentation.
