Today’s seemingly unsexy topic will actually help you build clientele. Really! Let me explain why.
We’ve all been there. Somehow we got behind on your notes. Boring, awful, annoying notes. If you work in an agency, you’re probably VERY familiar with this, but you have some sort of system that makes you get it done by a certain time (audits, standard of care agreements, bosses). If you’re in private practice, though you’re likely seeing fewer people and have more down time, it’s easy to get behind if you don’t have a system and a way of streamlining your work.
Here comes the harsh part: you know you’re supposed to be doing notes. It doesn’t matter if you take insurance or not. It doesn’t matter if you work with court-mandated folks or not. It is best practices and required by all of the counseling licenses that you take some form of notes. It’s not specified what form it has to be so if you hate SOAP notes, BIRP notes, etc. then don’t use them. If you’re not doing your notes, you’re walking around with the knowledge that you aren’t doing something you’re supposed to and that takes a toll. If you don’t have integrity in your business, it bites you in the ass eventually, sometimes in non-linear ways like not getting referrals. I got behind on my notes in August, had graduated some people from therapy and had a couple open slots. Weirdly, within 2 days of finishing my notes I had gotten the referrals needed to be full again. Take care of your business.
Ok, let’s talk templates. If you’re using an Electronic Health Record or a Practice Management System, you should have access to creating your own note templates. My favorite free EHR is Practice Fusion and my favorite paid practice management system (notes as a part of a convenient all-in-one system) is Simple Practice. Having used both over time, I created awesome templates that allowed me to quickly click boxes for the Objective, Assessment, and Plan sections (I was clinically-raised as a SOAP note girl and old habits die hard). So, I’m only on the hook for writing the narrative for the Subjective part. Literally a few sentences that take me less than 5 minutes for non-intake sessions. I end my sessions at 53 minutes, write my note, pee, and get the next client (yes, pretty much every working hour, I pee. Hydration is important). For those of you taking insurance, using Office Ally to bill took me 30 seconds per session and if you use a practice management system, there’s usually a button you can push at any time to submit all claims (no extra time required).
What does a template look like? It can be drop down or narrative. Here’s an example of a narrative I created when I used Practice Fusion. “Client is conscious, alert and oriented times four in no acute distress. Client was casually dressed with good hygiene. Mood is anxious, affect is congruent with mood. Client denies suicidal and homicidal ideation, intent, plan or means. Speech is of normal rate, rhythm and timbre. Thought content is appropriate. Thought Processes are intact. Insight, judgment and impulse control are all within normal limits.” Looks fancy, right, like it took time? Feel free to use it! I just chose from the different templates I created in each note (for my clients, usually a choice between mood being anxious, depressed, euthymic) and would edit after plopping it in if something was outside of that narrative, like if there was suicidal ideation or incongruence in presentation.
Most of these systems have “sticky” diagnoses, so if you diagnose you don’t have to re-enter them each time. Same with your treatment plan. I created a list of common homework assignments to check box into the plan section and as long as I’ve written the narrative piece, I’m done. Easy!
I also recommend creating a space in your schedule for notes where you aren’t allowed to do anything else until they’re done. They’re boring and annoying so of course you want to avoid it. I do them between session and if something comes up and I can’t finish one, I take the first few minutes of my lunch to knock it out. It’s tempting for me to finish with my last client of the day and leave that note for the next day but let’s be real, who wants to complete a note first thing? I knock it out before leaving so I’m TRULY done with my work day when I get home. It’s easier to focus on your non-work priorities when work is handled. It just feels cleaner that way to me.
What shortcuts do you use to streamline notes? Let us know in the comments!
Allison Puryear is an LCSW with a nearly diagnosable obsession with business development. She has started practices in three different states and wants you to know that building a private practice is shockingly doable when you have a plan and support. After retiring her individual consultation services, she opened the Abundance Party, where you can get practice-building help for the cost of a copay. You can download a free private practice checklist to make sure you have your ducks in a row, get weekly private practice tips, listen to the podcast, hop into the free Facebook Group. Allison is all about helping you gain the confidence and tools you need to succeed.