Therapy Notes Interventions NOT to Use for Insurance

Do you sometimes feel unsure about what to include in your progress notes for insurance purposes? Writing effective therapy notes can feel like an overwhelming task, especially when you want to ensure your interventions are clear, professional, and meet the required standards. But here's the good news—knowing what not to include can simplify this process and elevate the quality of your documentation.

When writing therapy notes for insurance, it’s important to choose words and interventions that convey your clinical skill and effort. Unfortunately, some common phrases—while nice—don’t add value to your notes and might even seem vague or unprofessional. Below, we’ll explore therapy notes interventions to avoid, show you better alternatives, and help you create notes that reflect your expertise.

Why Effective Therapy Notes Matter

Writing progress notes for insurance isn’t just a formality—it demonstrates the work you’re doing as a skilled therapist. Effective therapy notes:

• Showcase the clinical reasoning behind your interventions.
• Provide a clear account of treatment for continuity of care.
• Ensure compliance with insurance standards, so you can get paid for your work.

But vague or overly generic interventions like “built rapport” or “listened empathetically” don’t offer much context. Instead of documenting your role as a skilled mental health professional, they come across as something anyone could do—even a friend or family member. That’s why it’s crucial to use precise, professional language.

Common Interventions to Avoid (and What to Say Instead)

Here’s a list of frequently used intervention phrases that don’t provide enough clarity—and better alternatives that reflect the specific work you’re doing:

1. Built Rapport

Why to Avoid It: This is a fundamental part of any therapist-client relationship, but it doesn’t explain what steps you took to build that connection.

What to Use Instead: Describe why rapport might have been an issue and what you did to address it. For example:

• “Engaged client in a card game to create a comfortable environment for discussing feelings after trauma.”

2. Validated

Why to Avoid It: This is nice, but it’s vague. Often, when we say we’ve “validated,” what we mean is we’ve psychoeducated or normalized a client’s feelings or behaviors.

What to Use Instead: Be specific about what you addressed. For example:

• “Psychoeducated client about common anxiety triggers, explaining that their fear of public speaking is a typical response in social situations.”
• “Normalized client’s feelings about parenting stress during times of financial difficulty and shared related statistics for context.”

3. Asked Open-Ended Questions

Why to Avoid It: While open-ended questions are a fantastic tool, this phrase doesn’t explain the purpose behind your questions.

What to Use Instead: Highlight what you were assessing or exploring. For example:

• “Assessed client’s readiness for behavioral change by exploring their motivation and barriers.”

4. Acknowledged

Why to Avoid It: This phrase is friendly, but too vague. What does “acknowledged” actually mean in practice?

What to Use Instead: Go further and describe your action. For example:

• “Praised client for recognizing patterns of avoidance and encouraged them to celebrate progress.”

5. Listened Empathetically or Provided Empathic Support

Why to Avoid It: This is an essential skill for therapists, but it doesn’t showcase your professional interventions.

What to Use Instead: Focus on what you actively did during the session. For example:

• “Guided client through a conversation about unresolved grief, encouraging them to explore underlying emotions.”
• “Helped client reflect on their feelings of guilt, using active listening techniques to foster self-understanding.”

6. Client Was Receptive to Interventions

Why to Avoid It: This phrase doesn’t explain what “receptive” means or how it showed up in the session.

What to Use Instead: Be descriptive about the client’s engagement. For example:

• “Client practiced grounding techniques during the session and agreed to use them as homework.”
• “Client continued discussing traumatic experiences despite emotional distress, demonstrating resilience.”

The “Grandma Rule” for Writing Therapy Notes

Here’s a tip to improve the clarity of your notes—use the “Grandma Rule.” Ask yourself this question:

“Would my Grandma understand what this intervention means, or does it sound too basic?”

If your intervention could apply to advice from a well-meaning relative, it’s probably too general to include in therapy notes. Instead, focus on precise clinical language that showcases your skills and strategy.

For example:

• Instead of “Listened sympathetically,” try “Explored client’s feelings of self-doubt and provided constructive tools for reframing negative thoughts.”
• Instead of “Asked open-ended questions,” try “Assessed client’s coping strategies by asking about their use of exercise and mindfulness.”

How to Write Progress Notes for Insurance

Feeling overwhelmed by progress note documentation? Don’t worry—you’re not alone, and there are tools available to support you. Enhance your therapy note-taking skills with these guidelines and provide top-tier care for your patients:

1. Be Specific: Provide detailed descriptions of the interventions used, showcasing your clinical skills. Understand more about this approach by watching the Therapeutic Interventions List for 2023 video.
2. Focus on Outcomes: Connect your interventions to set therapeutic goals in the treatment plan. The outcome-based approach helps to demonstrate the effectiveness of your therapy sessions. For help setting clear goals, watch How to Write Therapy Treatment Goals. 
3. Use Clinical Language: Choose active, measurable actions over vague terms like “supported” or “helped”. This encourages more professional, concise, and comprehensible documentation.
4. Document Progress: Emphasize the tangible steps your client has made, and elaborate on how your interventions contributed to this progress.

Better Documentation Reflects Better Care

Taking the time to refine your therapy notes not only improves your clinical documentation but also strengthens the care you provide. By avoiding vague phrases and replacing them with detailed, professional interventions, you:

• Show your expertise as a therapist.
• Create compliant, insurance-friendly notes.
• Support continuity of care by providing future therapists with clear insights into treatment.

Want to enhance your therapy documentation even further? Sign up to get 23 Therapy Interventions for 2023 and elevate your progress notes today.