HOW Do We Keep Notes, and What’s In Them?
Progress Notes Survey Results, Part 3
By Barbara Griswold, LMFT (September 9, 2019)
Thanks to everyone who took my Progress Notes Survey. I clearly struck a nerve: 499 of you answered the survey, and left more than 850 comments, sharing your stress, frustration, anger, and feelings of inadequacy around this area of your practices. This is the third in a series of articles where I report on the survey results (if you missed the first two articles, click here)
Handwritten vs. Electronic? One question sought to find out HOW people kept notes. As can be seen in the graph below, results showed a full 40% of respondents still keep handwritten notes, even in this electronic age. 48% said they used some type of computer or online note-keeping program, and another 15% had devised their own way to keep notes on their computer (e.g. separate documents for each client). 1% stated they didn’t write progress notes.*
Popular Programs:Almost one quarter of all respondents reported they used SimplePractice to manage their practice and note (23%), followed distantly by TherapyNotes (7%), and Therapy Appointment and Theranest (both 3%). Others that were mentioned in the comments that got more than one mention (and number of “votes”) were MyClients Plus (7), OfficeAlly (4), iCanNotes (3), CarePath (3), Practice Fusion (3), NoteDesigner (3), Counsol (2), and Notes 444 (2), Valant (2), and Shrinkrapt (2).
What’s in your notes? Another question was “Which of these are covered routinely in your current progress notes” and gave a list of areas that state laws, ethical guidelines, and insurance plans may expect in our notes. Respondents reported high levels of compliance documenting session date and time, presenting issue and symptoms, client in session behavior/mood, and therapist interventions. But only 66% said they routinely charted session start and end times. Most insurance plans now require this; in an administrative audit or records request they may look for documentation of your charges.
Worse still, only 38% of providers say they document the support for their diagnosis and the client’s need for treatment. This is something we need to do better: this documentation may be what the client requires to get future treatment covered by insurance or a needed disability approval. Other areas that providers did not always document were changes to treatment plan (26%) consultations (50%), and client strengths and support system (37%).
Next time: Do other providers write treatment plans? Survey results continue…
Want to learn how to write brief but comprehensive notes? Check out my webinar “What Should Be in Your Client Charts — But Probably Isn’t: Writing Great Progress Notes and Treatment Plans”— click here
* Note total does not equal 100% as some respondents gave more than one answer