An essential component of every session note is documenting the interventions provided during a session. Yet many therapists struggle with documenting this aspect of therapy.

What is an intervention? An intervention refers to the clinical or therapeutic response of the therapist when addressing the issues presented by the client during the session. It answers the question, “what was the therapist’s contribution or participation in the session?” This can include advice given, homework assigned, education provided, coping techniques taught, and approaches you used in session to lead clients to deeper insight into their emotions and behavior.Why is documenting interventions so important?  Proper documentation of interventions is essential because during an audit a health plan may refuse to reimburse for the session if interventions are not documented, or if the documented interventions are inadequate. Also, if a client ever files a complaint against you, proper documentation of your treatment may be crucial to your defense.

Common mistakes therapists make when documenting interventions

The following are 6 common mistakes therapists make when documenting interventions:

1.   Your interventions are missing: While you documented the client’s statements and symptoms well, you didn’t include your response. From the note, it may look like you didn’t open your mouth in the session. This makes it impossible for an insurance plan or licensing board to assess your treatment, and can lead to lack of payment.

2.   Your interventions are too repetitive: You said the same thing in each session note.

3.   You used all checkboxes. Health plans (including Medicare) and licensing boards generally dislike only checkboxes for describing interventions. Checking “CBT” in each note without any narrative description of your treatment results in notes that are repetitive and have insufficient detail.

4.   You only listed one intervention. To show your active participation in the session, I recommend that you document at least three narrative interventions per 50- to 60-minute session.

5.   Your interventions are too basic or vague. Avoid documenting things you will do in each session, like “explored feelings,”  or “provided reflective listening.” Document only clinical techniques that you used in that session that rise above the baseline expected in all sessions.

6.   Your interventions are too “grandmotherly.”  Avoid interventions a grandmother could have provided, like “validated,” “praised,” “supported,” “provided compassionate safe space.” While these are essential to therapy, in session notes you should only document clinical interventions – ones that you had to go to grad school to learn.

FREEBIE:  A FREE Sample Interventions List

OK, so now I told you what you SHOULDN’T do.  But what SHOULD your interventions sound like?  Never fear – I won’t leave you in the dark!   Get my FREE Sample Interventions List just by filling out the form below.  You will immediately be connected to get your free Interventions List, which you can view, print or download.