What’s Wrong With Your Note Template
By Barbara Griswold, LMFT (September 4, 2023)
- 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?
- 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.