One question that I often get is, “how detailed should session notes be?” Great question.

And while we should keep in mind there is no “right” answer, it’s an important topic to explore.

First, let’s look at: Why are we tempted to get vague?

• Many lawyers will tell you to write vague notes. They feel this prevents you from writing something that could hurt you or your client.
• We are taught to protect client privacy when possible. You may have been specifically taught “less is more” when it comes to notes.
• We might be especially cautious when documenting sensitive topics such as child abuse, sexual assault, abortion, sexual orientation, gender identity, immigration status, illegal acts, and drug or alcohol use.
• A client may express concern about having something documented. I have had clients ask me not to document a diagnosis, their substance use, or an affair. This may be especially true for clients seeking political office or working in a top-secret position.
• A client is involved in the legal system (i.e. a custody battle), which may evoke concerns that what you write could have negative consequences.
• A minor client is concerned that their parent might see what you’ve written.
• We feel we can get superficial notes completed more quickly (hint – this is not necessarily true).

So, what’s the problem with vague notes?

The problem is that when lawyers give you the advice to write vague notes, they may not be thinking about whether those notes would help you pass an insurance audit or a disability claim. The reality is that notes that do not contain enough detail may be too superficial to pass an insurance plan audit, so that a client’s care is denied, and you (or the client) may not be paid. I’ve seen it time and time again.

Additionally, vague notes may not protect you if your client files a complaint against you, as there isn’t enough detail to demonstrate to anyone reading the chart that you gave the proper care for the presenting issue. And your vague notes may not support a client’s later application for much-deserved disability.

But can’t notes be TOO detailed?

Yes! Many therapists write OVERLY detailed notes, trying to capture EVERYTHING, since they aren’t sure what really is needed by insurance plans and other oversight entities. But they often include more than is necessary, and end up spending 20, 30, or 45 minutes on each note. This becomes overwhelming. These therapists may avoid doing notes, or HATE doing them, leading to high levels of stress and to burnout.

So what’s your advice?

So, while different documentation experts will give you different advice, I want to share my opinions about finding the documentation “sweet spot ” – which is somewhere between saying too much and saying too little – and talk about how long it should take. Remember, these are just my opinions, but they were formed after years of watching therapists get burned by not writing enough or writing too much.

The “sweet spot” between overly vague and overly detailed notes

1. This is the client’s official medical record, and you must document what you are treating the client for. If the client’s presenting issue is an affair, I believe it is too vague to write they are “dealing with a relationship problem.” It the client has been assaulted or is pregnant, it is too vague to state that they are dealing with “a significant life issue.” It would be equivalent to your doctor writing in your medical record that you were dealing with a “significant body issue” when you broke your leg. Some level of detail is necessary; for insurance, a disability claim, or in case of a complaint, your note needs to record the specific complaints and symptoms.
2. Recording details will also make it easier to demonstrate the client’s progress. Get in the habit of documenting the frequency and severity of symptoms. For example, recording the average number of hours of sleep or how much alcohol the client is drinking each day or week can help prove progress.
3. However, every detail does not need to be included. The fact that a client was abused as a child may be significant to note for the reader to understand the client’s symptoms and trauma history, but you need not include every detail about the abuse. Try to document the elements of any past issue that are most relevant to the client’s current mental health issues. And I would suggest that you only need to document details about the client’s presentation when it was is unusual, omitting if they were on time or well-groomed.
4. Get consultation when you are concerned that what you are writing could have negative consequences, such as when involved in legal cases or child visitation battles. Consider hiring a documentation expert off my Free Practice Coaches list at theinsurancemaze.com/consultations.
5. Don’t allow a client to persuade you NOT to document something. Remember: You are keeping an official medical record, and you cannot hide a diagnosis or certain case facts. Also, letting a client persuade you in this way can serve as a poor role-model for clear boundaries and ethics.
6. Some level of detail about your INTERVENTIONS should be included. Avoid checkboxes. Add 2-3 sentences describing what you did in this session, and don’t copy last week’s sentences. Give examples of how you used medical approaches (ex. “Used CBT to help client identify cognitive distortions like black and white thinking with ex-wife.”) Again, this detail allows a reviewer to judge the appropriateness of your care in each session.
7. You can’t write a vague progress note and keep a second psychotherapy note (aka process note) where you hide the details. The progress note is the official medical record and must contain all relevant facts of the case. While HIPAA does allow you to keep a separate psychotherapy note, think of this more as a place for your case conceptualization, not facts. In many states psychotherapy notes are not fully confidential, allowing access to clients and court access in certain cases,
8. Consider – should you talk to clients up front about the need for diagnoses and session notes? This would allow them to bring up concerns. I did not spell this out verbally with all clients, as it could be anxiety provoking to a new client, but I did when the client had sensitive presenting issues and for those involved in court cases. I suggest you add something about your need to diagnose, keep session notes and treatment plans, and your court appearance policy (and fees) in your Informed Consent.
9. If a client is concerned about revealing personal information to an insurance plan, remind them that health plans aren’t generally interested in their life choices and relationship issues. In an audit, they will be looking at the completeness of the therapist notes, as well as the client’s symptoms, impairment, and progress so they can determine the need for treatment. Again, if these are not documented in a detailed way, the client’s sessions may not be covered.

How long should notes take to write?

I believe notes should average around 5-7 minutes each, but of course longer for non-routine sessions, crisis sessions or those with multiple clients in the session. If you are writing notes that take much longer, you are likely writing too much.

So here’s the takeaway: It can be risky to write vague session notes with the primary intention of getting notes done quickly or to protect clients. You can’t choose what information to include and what to leave out in order to try to help clients. Plus, you can’t know what will be needed later to help a client or to defend yourself. Your job is to document what occurred in the session in a way that factually and clearly explains the client’s symptoms, impairment, your interventions, and their progress.

The good news?

The good news is that you can stop hating documentation or procrastinating and falling behind. You can learn to write BRIEF, better notes that will please insurance plans and oversight bodies. Check out my recorded course “What’s Missing From Your Charts: Writing Great Notes” and “How to Write a 10-Minute Treatment Plan” at theinsurancemaze.com/store – both will even give you easy templates for notes and treatment plans with loads of samples that you can start using in your practice today.