Documenting Consults: Protecting Your Assets

I've had a few therapists ask me recently about how to document a consultation with other psychotherapists. "When do I need to do it?" "What should I include?" "Where does the note go?"

My biggest piece of advice is first, to actually DO it! Many counselors in private practice don't think about how this simple task could save lots of trouble down the line. It doesn't have to be intense or scary (we'll get into that below), but it can be super helpful. 

So, let's get into the What, When, Why and Where of writing a consultation note...

Why

Documenting consultations with other professionals serves a few purposes. Firstly, it proves that you took action to be ethical. Some ethical concern came up and you took the appropriate action. Without documentation, how can your prove that happened? Answer: You can't!

It also helps you clinically. It's impossible to remember everything that goes on with your clients or even with your professional growth. However, if a situation ever comes up a second time, you now have a previous decision documented. You can go back and review without relying on your unfortunately, very fallible memory.

When

I recommend documenting a consultation with a colleague any time the issue is impacting the clinical work or any time it's an ethical concern. You may be part of a regular consultation group and do case presentations. It's not necessary to document each of those instances... unless it meets criteria A or B above.

There are times when ethical dilemmas arise in the moment and you don't have time to consult before you need to take action. These situations are also an excellent opportunity for consultation. Discuss the possible actions you could have taken and get feedback on how to proceed from that point on.

What

Now we're digging in... what in the world do you include?! If you only take away one thing from this post, focus on this word- rationale. The purpose of a consultation is really to document the discussion around the rationale for your decision. 

Include who you talked with and which ethical principles apply. Identify why you needed this consultation. Describe the action you will take and more importantly, the reason for your decision.

Maybe your client shared a significant issue in the last session and it's an area in which you're totally unfamiliar so you consult with a colleague to determine if you need to refer out to a specialist, continue treatment with supervision, or simply review some resources.

Perhaps your client presented you with a pricey gift (let's go with... a Caribbean cruise) and you graciously did NOT accept. Your client seemed miffed and you'd like to consult on how to proceed at this point because you have not had this experience before.

Or maybe your client is requesting ALL of their treatment notes out of the blue. You feel this could be harmful for them and want to be prepared when talking with them about it. You want to make sure you are considering all the laws, ethics and clinical issues at play. 

Note: A distinction is made here with countertransference issues. Often, issues will come up that prompt us to seek our own process and work through our own emotions. Although this does impact your clinical work, the distinction here is that the focus is on you. In some situations you may actually seek consultation as well as your own therapy. 

Where

Now that you've got this excellent consultation note, where the heck does it go? As long as it's specific to the client and a clinical issue with them, put it in their client file. If it's specific to yourself (this would be rare, but you never know!), create a consultation file and put it there. 

Consultation notes = easy... right?! 

Our work is so meaningful and often fun but the unknown, the scary, and (gasp) mistakes are bound to happen. That's where documentation comes in to save the day (cue super hero music). 

Just be your wonderful, ethical self and write about why you're doing what you're doing. Easy peasy. 

Still not totally comfortable with the whole note-writing thing? Check out my free Private Practice Paperwork Crash Course. I talk a lot about notes and even give you some samples to look over.