The Fastest Way to Write Your Notes

Not surprisingly, most counselors are looking for any way to make writing notes faster. The most common method for doing this is to skimp on content or just avoid writing altogether (um, NOT what I'd recommend, btw). 

I hear from therapists every week who are behind in their notes.... and I'm not talking one or two days behind. I'm talking weeks, sometimes months behind in notes. Yes, it's that common. 

Feeling better already? Good! Now let's get you rocking those notes in no time.

Prepare yourself, because your initial reaction will be to balk at my recommendation. But if you're behind in notes, it is likely going to lift a huge burden off your shoulders if you really implement it... I'm talking about collaborative documentation (sometimes also called concurrent documentation). 

That's right, actually writing your notes with the client in the room. By the time your client leaves your note for that session is done. You see your next client (or go home) without worrying about any notes to complete. 

Sounds a little bit weird but a lot awesome, right?

Now some of you may have had a negative experience with this from working in an agency. But I'm going to outline how to get this done in a clinically powerful way. So stay with me here...

What is collaborative documentation?

Collaborative documentation is writing your session notes in conjunction with your client. It's not the same as jotting down your thoughts on a "secret" notepad you hold between you and your client. It's actually including your client in the note-writing process.

At the end of the session, you and your client transition to talking about what just transpired. What insights were discovered? What progress was made? What was learned? What action will be taken before next week?

I know, I know. You're thinking, "I hate writing notes. Why would my client want to do that?"

Well, there's actually a good body of research that shows clients like it! Why in the world would that be?

Here are some of the benefits of collaborative documentation...

It increases client involvement. Yup, that's a bold claim but it's true... provided you keep one key thing as the focus. This is your chance to get honest feedback from your client.

We know that consistently asking clients for feedback and reviewing progress improves therapy outcomes all the way around- engagement increases (e.g. no more no shows) and clients report being more satisfied with the process. 

Use this opportunity to reflect with your clients on how that session went for them. What stood out to them as the main focus? What stood out to them as something they could do differently over the next week? What insight surprised or motivated them?

Have the discussion and write it down together. Voila, you're done!

It creates transparency. The old-school thinking of us (the "experts") and them (the patient) is quickly fading. People are no longer satisfied to blindly follow advice. They research things ahead of time (hello, Google!) and know their rights. 

When you're transparent about the notes you take for sessions it increases the amount of trust built in the therapy relationship. Your client no longer feels as though you're hiding something and wonders about it. 

It makes you think about your notes differently. Trust me, you'll think about notes differently when your client is watching you write them. The note will automatically have more meaning. It becomes personal. 

Rather than something required by a licensing board or insurance company, your client notes become what I like to call the record of your client's journey with you. It's almost like a journal you write together. Bet you've never heard that analogy about notes before!

It provides you the means to transition and end sessions on time. One of the most common things I hear from counselors who have difficult writing notes regularly is that they end up with very little time between sessions because it's difficult for them to end session on time.

Now, that's partly a clinical issue I'd encourage you to consult with someone about but some of it is just lack of training in how to gracefully transition your clients. Introducing this as a closing exercise can be a nice way to provide that transition for clients who have difficulty respecting that boundary. 

So, what do you think? Are you thinking about trying it out? I recommend you try it for at least two weeks to give it a fair shot. The first few times may be a bit awkward, so give yourself (and your clients) time to get used to the process and individualize it a bit. 

Then jump back over here and let us know how it's going! 

Looking for more tips on saving time while keeping your notes awesome? Check out my October training series.** We're going to rock your documentation in just four weeks with weekly videos and webinars on all things paperwork.

Happy writing!

Like the tips in this blog post? You can find more tips like this in my book: Stress Free Documentation for Mental Health Therapists: The Complete Guide to Progress Notes, Treatment Planning, and Medical Necessity

For more tips sign up for my FREE Private Practice Paperwork Crash Course.