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7 Tips on Improving Documentation and Your Process

Documentation can be a stressful, challenging, overwhelming, and time sucking part of the job for all of us. There isn't a job in this field that doesn't require documentation at some level. Therefore it's important to have and understanding of what you can to do improve it and your process for completing it to save time, energy, and sanity.

1. Know what documentation you need to completed

This may vary slightly from agency/practice/organization to another. In say Child Protective Services (CPS) or similar areas of the field documentation may have an intensely high requirement. Where as outpatient or private practice it may be much more simple and to the point. You must understand key components needed in your documentation to indicate how or why someone is medically meeting necessity or in need of a higher level of care or service. Generally you want to understand symptoms, intervention, client response, and the plan. Additionally, in general clinical practice your key documents for clinical care include Assessment, Diagnosis, Treatment Plan, Progress Notes, Discharge/Termination Summary and any other necessary communication notes.

2. Use a template

Once you determine what needs to be in your notes, it will save you time and energy to follow a template. SOAP Notes (Subjective, Objective, Assessment, Plan) can be part of that template including a brief mental status exam (MSE) for each session. If you focus on the key elements of a SOAP note or another note format similar it allows you to focus on a few sentences to capture the clinical necessary information needed for proper documentation while simultaneously keeping it short and quick when it comes to your documentation. You don't want your documentation to become overwhelming, cumbersome, draining, and ultimately behind. The timeliness of your documentation can become and ethical issue as well as an issues with accurate documentation and the impact on insurance audits. Ideally your documentation (as a general and may change based on requirements of documentation for certain areas of the field) shouldn't take you more than 5 minutes a note.

3. In most cases - Less Is More

Again with some exceptions where every detail matters, less is usually more. What do I mean by that? Keep in mind that your documentation can be harmful to a client in several ways and therefore intention thought must be present when documenting. Clients have the right to access their chart at any time. With that in mind, would what you wrote in your notes be harmful to a client if they were to read them? If your charts were needed for court or from other outside resources, would that be harmful in any way to a client? These are things to keep him mind when charting on a clients symptoms, challenges, barriers, thoughts, etc. Keep them short and as general as possible. You can keep separate psychotherapy notes that are not an official part of the client chart but has more detail for your to remember as treatment or services progress.

4. Focus on facts rather than opinion and subjective statements, focus on progress and adjust as necessary

It can be easy to get lost in documentation on how WE think or feel about what is happening with a client or why. However, these are not necessarily facts and could be very subjective and at times harmful when written in documentation of the clients official chart. Avoid making statements such as "client appears to be a bad friend" or "client is suffering from depression," rather it would sound more like client reports she "feels she is a bad friend" and she discussed her reasons behind her thoughts and clinician supported client in confronting her negative thoughts and used reframing techniques. Or When documenting stick with that what is factual about what the client has said, is experiencing, or has responded. In the treatment plan, measurable outcomes should have been identified and when documenting reflect back on how a client is meeting their treatment plans goals through measurable change.

5. Create boundaries and timelines

It can be easy to get get overwhelmed by documentation and fall behind. Find ways to set boundaries to not take your work home with you, get them done at the end of the day, ensure you are ending sessions at the 53 minutes mark (for insurance) to ensure you get your full hour for billable purposes but have left yourself time to write your note, use the restroom, and possibly grad a snack or at least get up and move a few minutes. The longer you go between session and documentation the more difficult it can be to be truly accurate in your representation of the what truly occurred and what was said. Self-care is setting boundaries for yourself with work and personal life. Give that gift to yourself.

6. Know what to include and what to exclude

This can be a tricky one. So lets remember that your client has consented to treatment but may not consent to all of the information you are writing or that outside parties have not consented to treatment. So what does this mean? This means that a client might not like or feel comfortable with excessive detail of their sessions in their chart notes. It can be initial good practice to review a few notes with a client to see how they feel about what is written and/or at the end of session recap what you are chatting for a client. Also note, is there anything you client has expressed they want kept from the record, within reason.

7. Know your company/agency protocols and requirements

Similar to but not the same as "know what documentation you need to complete." That is the specific documents themselves that are required for ALL charting. Each agency/company may have additional forms and protocols that employees are required to follow in terms of documenting. These should be outlined in your policies and procedures as well as your orientation or onboarding process. Take notes on what needs to be done, if there is an order of procedure, and any nuance notes to help you stay on track and ensure proper and timely documentation is completed.

Until next time. Stay Motivated!

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