What’s Wrong With Your Note Template

By Barbara Griswold, LMFT (September 4, 2023)

Colleagues: It’s time to have a heart-to-heart talk about your note templates.

What’s a note template? Templates are those little structured formats you may be using to write session notes. You may be using a template that came with your Electronic Health Record (EHR). Or maybe you got yours from a colleague or former supervisor.

What you may like best about your template is that it has numerous checkboxes, making it quick to fill out. The problem with most of these templates is that they don’t offer many narrative sections where you can customize the note. All of those checkboxes means you can end up with notes that are vague, superficial, and sound exactly like last week’s note.

“But Barbara,” you ask, “if these templates are offered by my trusty Electronic Health Record, SURELY they must please insurance plans, right?” Don’t count on it. Read the following excerpt from Blue Cross Blue Shield of Texas’s policy manual which captures a common insurance plan sentiment:

“Templates can be useful tools; however,…Blue Cross and Blue Shield discourages templates that provide limited options and/or space for the collection of information, such as checkboxes, predefined answers, choices to be circled etc. Templates that just elicit selected information for reimbursement purposes are often not sufficient to demonstrate that coverage and coding requirements have been met…”

“Templates also make every patient visit or treatment appear the same. Each medical record must be specific to the individual patient. The reviewer of the chart must be able to discern the patient’s condition and services. Atypical patients may have multiple problems or additional interventions that must be documented in detail. Documentation is considered cloned, copied and pasted or carried forward when each entry in the medical record for a patient is worded exactly alike or similar to the previous entries or when medical documentation is exactly the same from patient to patient… Documentation in the medical record must be specific to the patient and their situation at the time of the encounter.”

Let me give you an IMPORTANT example. Many templates automatically enter the scheduled start and stop time of the session, but do NOT include the actual session start and stop times of the therapy portion of that session, which should be recorded in the session note, and should be different for each session to be credible. Without this unique session documentation, the therapist has no proof that time requirements have been met for the CPT code used for that session.

I also know therapists who, in an audit, were asked to pay money back to a health plan because each session note was too similar to each other, or was cut and pasted from client to client, or session to session.

But even the best templates tend to fail us in THREE VERY KEY areas. Look at the notes you are writing and ask yourself these questions:

Am I recording specific details about the TOPICS the client discussed in that session?
Am I recording specific details about the SYMPTOMS the client discussed in that session?
Am I recording specific INTERVENTIONS I did that were appropriate for those topics and symptoms, and that were unique to that session?

Let’s talk more about this last one — interventions. If EVERY WEEK in the session note, you check “CBT therapy,” “reflective listening,” and “exploration of feelings” as your interventions, the reviewer has no sense that you are responding to the client’s unique issues of that session. A reviewer has no idea how you used CBT, what specific comments, interpretations, or advice you gave, homework you assigned, how you went about exploring the client’s feelings, and whether it was appropriate. And importantly, if that client were to file a complaint against you, those three checks will not defend you very well, as they don’t adequately reflect the details of the service you provided, and how it was appropriate given the client’s presentation.

So, what’s my advice?

You don’t have to stop using templates. But if you are using a template that is leading to vague, superficial, and overly-general notes, find ways to add narrative information about THAT session and THAT client and your SPECIFIC interventions/responses to the client’s presentation in that session. If you can’t do that, ditch the template. A note needs to be able to stand on its own, so the reviewer gets a clear idea of what each person said and did in the session.
Some EHR programs allow you to customize a template to make it more useful to you, or to use one open narrative box for your note. In the latter case, consider cutting and pasting your own template, or at least the headings for areas you want to include in your note, but not all the checkboxes.
One last point: We tend to tell ourselves that note templates with lots of checkboxes will take less time to fill out, and allow us to spend less time on our notes. But in my experience, with a little practice, you can write much more meaningful notes without an over-reliance on checkboxes, and write them just as quickly. If you need help writing quick and detailed notes, check out my pre-recorded course “What’s Missing From Your Charts: Writing Great Notes“, which comes with three downloadable templates (including one of my own) or sign up for a consultation with me to get help with or feedback on your notes.