How Do You Catch Up on Notes?
By Barbara Griswold, LMFT (September 7, 2020)
I consult with therapists all over the country who have fallen behind — sometimes months behind — in writing progress notes, or have large gaps in notes. Some of us even do “routine binge note-writing” — for example, each weekend writing all notes for the week. If this is your situation, don’t judge yourself too harshly — it’s amazingly common. But it can be a big source of stress, like a debt that grows daily. And the longer the time lapse between the sessions and your notes, the less reliable they are.
If you don’t remember what took place in past sessions, should you try to go back and catch up? Or should you just focus on writing today’s notes, and go forward from here? You may worry that choosing to catch up will give you no time to work on current notes, and vice versa.
For answers to these questions, I interviewed Maelisa Hall, Founder of QA Prep.com. Maelisa is a fellow private practice paperwork specialist. But one of her unique areas of expertise is helping therapists who have fallen behind in their notes.
Barbara: So Maelisa, how about it? Should you bother going back to try to fill gaps in progress notes? It can often feel so overwhelming.
Maelisa: Yes, it can. But in my opinion, any note is better than no note at all. So, I do recommend that you add a note for every date you know a session occurred.
B: What if you remember nothing from the session?
M: If you remember absolutely nothing about that session, I suggest you write something really basic like “Session Date: 3/20/20: Client attended video session. Worked on progress toward treatment goals. Next session scheduled for 3/28/20.”
B: Obviously, it’s best to write as many details as you can remember — i.e. if you know you worked on the client’s anxiety in all sessions, you could say “focused on client’s anxiety and anxiety coping skills,” right?”
M: Right. But here’s my point: Don’t avoid writing the late notes because you are trying to remember as much as you can. It is better to write something, and then move on to the next note.
B: I know it is important also to document the date that you wrote the note, so that you don’t give the appearance that the note was written on (or right after) the session. How do you do that?
M: In the note, you do need to record both the session date and the date the note was written. I usually recommend identifying the session date at the top or beginning of the note. Then after you’ve written the note, identify the date the note was written next to or below your signature.
B: So, could this be a sample note? “4/16/20: Video session. Client worked on goals outlined in treatment plan. Barbara Griswold, LMFT [note written 08/28/2020] “?
B: So, do you still sign a late note?
M: I do recommend that you “sign” your progress notes, even the digital or online ones, even the late ones. If you are using Google Docs or Word to write notes, the technical way to show that a document is “signed” is to put your name between slashes, like this: /Maelisa Hall, Psy.D. PSY25295/ Maelisa Hall, Psy.D. 08/28/2020. Your license number could also be next to the name or outside the slashes.
B: What if I need to make changes or additions to a progress note later?
M: You may want to add an Addendum note, with a separate date and signature.
B: What do you think about just writing a treatment summary if your catch-up notes are superficial?
M: I think a treatment summary can be a great strategy. If you can’t remember details about what happened in specific sessions, the treatment summary can provide more clinical information. The progress notes are more a record of when you met with the client. Again, put the date you wrote the summary on the document. But remember: While a treatment summary is a great addition to a client chart, it doesn’t take the place of progress notes.
B: So, Maelisa, I read the Catch Up Plan outline you offer therapists, and was really impressed. This free downloadable guide offers a really practical, step-by-step outline on how to catch up on notes.
M: Thanks! Folks can get the Catch Up Plan sent to them by going to https://www.qaprep.com/summer-paperwork-blitz . I also offer individual consultations — personal assistance without judgement — to help you develop a Catch Up Plan that works for you. Just contact me via my website at www.qaprep.com.
A final thought from Barbara: If your progress notes aren’t what they should be, you don’t know what you should be writing, or if you have fallen behind writing notes, it’s time to learn how to write detailed, quick notes that meet all legal and ethical requirements. Check out my webinar “What Should Be In Your Client Charts — But Probably Isn’t” — click here.