Do you ever find yourself in the middle of writing a progress note and you struggle to find the right words to describe what actually happened in therapy?
If you answered “Yes”, you are not alone. A lot of clinicians struggle with this issue. It is one of the main stumbling blocks clinicians run into when documenting in a progress note, and yet its one of the more important things we need to be able to do.
All psychotherapy progress notes have a lot of parts to them, but three pieces that are key to this discussion are the elements related to how the client is doing I “the world”, the work you and the client are doing in the session, and your assessment of how they are doing overall.
When we think about how the client is doing outside of the therapy room, this is very often captured in the conversations we have with them as they share their story. The challenge, of course, is what of that story is really important to document in the progress note? While there are times when details of the story are critical to capture, more often its in their perceptions and responses that are more key. How did they respond emotionally or somatically to an event or situation? Did they utilize a technique you have been working on in therapy? How well did it work? How was their response different than previous situations?
When we think about what’s happening in the therapy room, we are focused on the machinations of the work we’re doing, their engagement in the process, and how well it was received.
Of course, we are always assessing, and assessment is key to documenting how the client is responding to treatment, so it needs to be there.
The most effective way to accomplish all of this, of course, is by using technical language. It’s more specific, it saves precious time, and it allows for your progress notes to be very specific while also being briefer. It’s a three-way win!
The problem arises when we aren’t very comfortable with using technical language. We prefer to describe in detail the thoughts the client had related to an experience they had, and deeply what they thought about them, than to use the term “ruminated”. Of course, both are fine to do. One just takes longer.
In our assessment, we might spend a couple of sentences describing how the client has shown consistent low levels of depression over a longer period of time in the assessment portion of the note, or we might document the client continues dysthymia. Again, neither of these is right or wrong, and will not create trouble in an audit. One just adds precision.
Learning our language provides us with a certain amount of freedom to be able to tackle all of the elements of our work. Our assessments become cleaner, treatment plans become more straightforward, and progress notes take less time to write.
But not everyone is great at learning technical language. For those of us who struggle with this, it might be a good idea to something simple like buying a notebook and building a list of terms that might be useful for you to use during your documentation. It might feel a little clunky to do this way, but the action to actually write it down and having access to it on your desk will help you start remembering the terms you use more often.
And when you take a Continued Education course, along with learning new skills, pay attention to the language that come with it, and add some of them to your lexicon.
By expanding the precision of your clinical language will ultimately make you more effective in how you document your work and will ultimately change how you see your clients and the clinical work you are doing with them.