Life Hacks for Therapists: Mastering the Art of Case Notes and Documentation

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Life Hacks for Therapists: Mastering the Art of Case Notes and Documentation

Hey there, amazing therapists! Today, let’s chat about something we all know is crucial but can sometimes feel like a chore – case notes and documentation. Keeping on top of these can feel overwhelming, but I’m here to share some life hacks that will make this task more manageable, while also enriching your understanding of your clients. Think of it like journaling about your sessions — it’s an opportunity to get crystal clear on your case conceptualizations and the path forward. 

So, let’s dive into some strategies that can make your documentation a breeze!

Concurrent Notes: In-the-Moment Insights

Concurrent notes means taking notes during your therapy sessions. It’s much easier during video sessions, but you can also use a stylus and tablet in face-to-face meetings.

This method helps you capture insights and important points in real-time, which means you won’t have to work to recall details later. It keeps your observations fresh and accurate.

An added bonus? You can share these notes with clients as part of their homework. It helps them see progress, and it keeps clients engaged in the therapeutic process.

  • Pros: Immediate documentation, accurate details, when your session is done, so are your notes.
  • Cons: May distract some clients or disrupt the flow of the session.

Time Blocking: The Daily Routine Approach

Time blocking means setting aside a specific time each day, either in the morning or evening, dedicated solely to updating case notes. By making it a regular part of your daily routine, you ensure that notes are always up-to-date. This method helps in compartmentalizing tasks and reduces end-of-week documentation overload.

  • Pros: Consistent habit, notes are regularly updated.
  • Cons: Potential for forgetting finer details if too much time passes; can be overwhelming if you have a heavy caseload.

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Between Sessions: The Short Break Method

This method involves using the time between sessions to quickly jot down notes. It requires having a gap between clients, which can be used for note-taking. It’s a way to ensure that your observations are as fresh as possible, without disrupting the session. 

  • Pros: The details are fresh in your mind and there is less to recall later.
  • Cons: Requires having enough time between sessions, and can be challenging if therapy sessions run over. It also eats into your breaks, which are necessary boundaries for therapists.

Finding the Method that Works for You

Every therapist is different, and so is every client, and every session. Some days, concurrent note-taking might work best, while on others, time blocking will be your savior. The key is flexibility and finding what rhythm suits your style and schedule.

Here are a few more tips for making your case documentation easier: 

  1. Stay organized: Use digital tools or apps designed for therapists to keep your notes organized.
  2. Practice self-care: Remember, taking a break is important too! Balancing documentation with self-care ensures you’re at your best for your clients, and yourself. 
  3. Keep learning: Stay open to adjusting your methods as you learn what works best for you and for your clients.

In closing, documentation doesn’t have to be a drag. With the right strategies, it can be an integral and fulfilling part of your therapy practice. 

And if you’re in the right environment, it can take minutes every week, not hours. Some therapy work environments minimize administrative task so you can focus on what you do best — create positive change in the lives of your clients. If your current workplace isn’t aligned with that vision, I encourage you to explore other opportunities, including the group private practice opportunities at Growing Self. 

Here’s to finding the case documentation strategies that work for you!

With love, 

Dr. Lisa Marie Bobby 

P.S. — Are you at risk for therapist burnout? Take my free quiz and find out!

  • 03:22 The Importance of Case Notes and Documentation
  • 04:16 Strategy 1: Concurrent Note Taking and Treatment Planning
  • 10:10 Strategy 2: Time Blocking
  • 12:39 Strategy 3: Short Break Method
  • 15:23 Deepening the Case Notes Experience
  • 25:13 Exploring Your Options

Lisa Marie Bobby:

Do you ever feel like case notes and documentation are like the bane of your existence when it comes to your day to day work as a therapist? Uh, if so, just want to normalize that. I mean, I, few people love doing notes and treatment plans and documentation, but I’m here to tell you that there are some ways of approaching this that can make just managing this workload so much easier.

And also there are some different ways of even thinking about what’s happening with case notes and documentation that can be incredibly valuable, both for your work with your clients, but even for your own self awareness. And dare I say, Long term professional trajectory. If you’re curious, good. And I’m so glad that you’re here to have this conversation with me today.

I am Dr. Lisa Marie Bobby, and this is love, happiness, and success for therapists, a podcast devoted to the wellbeing and professional satisfaction and joy of clinicians, just like you, because Hey, let’s get real. We have all chosen. A challenging yet very meaningful and rewarding profession, but in my experience, and I’ve been doing this for a while, if therapists like you, like me, don’t get support mentoring, just, you know, somebody standing next to them to help figure out how to do all of these things and do it the right way.

Do it well with style, grace, but also some happiness. Um, this profession, I think in a different way than most others can start to take a really, uh, real toll on your mental, emotional, even spiritual wellbeing that can accumulate and burn out and really not having a good time. And for, for many therapists, unfortunately, um, you know, Taking the final solution of exiting the profession because of not know knowing how else to be well and, um, create the kind of professional experience that we’d hoped for when we first set out to do this.

Right? So that’s what we’re here doing every single week and every week. I am addressing different aspects of our shared profession to bring you again, new ideas, guidance and, and the all important community. That we all need. So on today’s show, we are talking about what can again, feel like a chore can be very boring, but it’s also just a crucial and fundamentally important part of our role, which is case notes and documentation.

And so, uh, over the course of the next little bit here, I’m going to be sharing some hacks that will make this feel more manageable for you, but also how to incorporate some new strategies that really allows you to, um, I think develop a much more insight into what’s happening with your clients, but also get some more insight into what is happening with you professionally on a long term basis.

So to begin, let’s dive in by talking about some of the different strategies you can employ just to make this all feel easier. I’m going to talk through the three big strategies that typically work best for most people so that you can think through whether or not you’re doing these or whether or not some of these might be useful additions to what you are doing in order to make this feel easier for you.

So one of the things I will suggest is a little bit controversial, but it is the method that I use. It works really well for me. And in my experience, clinicians who do it this way, it makes just case notes and documentation very, very easy. And this is concurrent note taking and treatment planning. Um, which means, uh, it is taking your notes during your therapy sessions, um, either typing them into your electronic records management system, or as I have done in the past, like writing them out on paper while I’m sitting there talking with my clients.

Um, I have also, like back in the day, I would write notes on paper while I was talking to clients and I would scan them, upload them to my system, shred them of course. Uh, but also it’s. Exploring, you know, iPads that have like stylus capabilities found that that was actually a really good solution for me, too.

And this can really help on a variety of different levels because when I. We are taking notes in real time. We are capturing insights. We are capturing important points so that we’re not, you know, relying on our memory to recall details that we would otherwise forget. I think it helps, you know, me keep my observations.

Much more fresh and accurate. And also when I do this, I actually remember more of my sessions because of having written it down, even if I’m not necessarily always reviewing all of my notes and research, um, supports that when we take notes. When we encode ideas into writing physically, our memory is improved as a result.

And I think that on a deeper level, it gives us an opportunity to just kind of process what’s happening with our clients on a deeper level. As an added bonus to the strategy, in addition to our memory and recall, um, I found it also to be very valuable to share these notes with clients sometimes, and sometimes people hear that and they have a little sharing my notes with clients.

What are you talking about? I’ll just say I don’t ever put anything in case notes that I’m not talking about with my clients. First of all, so there’s nothing in there that would surprise people. But also when I’m taking notes, Um, you know, I’ll be writing about like the key points that we’re discussing if we’re talking about homework assignments or things that they should be doing or thinking about in between their sessions, that goes in there too.

And I’ve had so many clients be like, Hey, can you share those with me? And so if you’re using an electronic records management system where you could post that to your client’s account, that could be really helpful. Um, back in the day when I was doing things on paper, read things down on paper, you know, I would do my scan and instead of shredding those notes, just hand them to my clients.

Like there you go. Certainly I also encourage clients to be taking their own notes while we’re talking because it helps them remember and process information and recall details just in the same way it helps me. So that is obviously, you know, more beneficial for them if they’re taking their own notes.

But, but that could be a nice experience for clients to have my records of what we’re talking about, what they’re supposed to be doing. Uh, they have felt cared for. I think when I’m able to share those with them, with them now, um, you know, there are many advantages in my experience doing concurrent case notes for what we just described, but also for the reason that by the time your session is done, your notes are done and you don’t have think about it again, which, you know, in my opinion, it’s probably the biggest advantage.

I have also done concurrent treatment planning with clients where we’re actually sitting there together talking about their diagnosis and why I believe that that diagnosis fits. And of course, we’re talking about psychotherapy now. It’s a little bit different with coaching, but, you know, even with coaching.

Goals. Like, here’s why I believe this is what’s going on. And here’s why I think that this is what, you know, treatment should look like, or what our path forward should look like. And that we are developing that together, collaboratively, and I’m writing it down as they talk as we’re talking. So it’s, you know, we’re doing it together.

I think that that’s another really important advantage of concurrent notes for me is that like collaborative feel. Now, I do think that some clinicians have a mindset around this that is negative. It is. I wouldn’t be present if I was doing that with my clients. They wouldn’t feel like I was there with them in the moment.

And you know, you have to decide for yourself as to whether or not that feels true for you. I’ve managed this by just at the very beginning of. Relationships with clients. I’ll say part of my process is to take notes as we’re talking because I care about you. I want to remember what we’re talking about.

So you might hear me typing over here a little bit and that’s what’s going on. I will share any of the notes. I’ll tell you what I’m writing down if you’re ever curious, but just so that they know what’s going on. Um, I have not personally found it to be something that makes me less present. I feel like it makes me more present with what clients are saying.

Um, but if you have, you know, core beliefs around that, those could either be worth it. Challenging or exploring, or you might not want to do concurrent notes, which is completely fine either way. So, um, another strategy that many clinicians use that really works well for them is related to time blocking the daily routine approach to case notes.

And so what this is, is really just setting a specific time every day or, or times each day in the morning and late afternoon, maybe both of those for some predefined time, 30 minutes, 45 minutes. 15 minutes, whatever it is. Um, when I’ve done this in the past, I personally will set a little timer that helps me focus.

Be like, I’m not supposed to be doing anything else right now, except my notes, because otherwise I might start doing other things besides notes, which defeats the purpose. But really having like a container for this is my time to do notes. Cause by making it part of your daily routine, um, you just make sure that your notes are always up to date.

Like I do my morning notes. At the noon hour, I do my afternoon notes at 4 30 and then I’m done. And it really, I think just having that dedicated time, it reduces the possibility that documentation is going to start, you know, creeping up on you or all of a sudden you have like 50 case notes to do. Nobody wants that.

So just, you know, having daily little routines to do that will make that a lot easier. I said there are pros and cons of this too. I mean, advantages are certainly having consistent habits and if you’re able to do this, it means your notes are regularly being handled. You have that time. This is when I do paperwork and then it is done.

Now, the cons here is that if it is difficult for you to time block or if you know, you’re in an environment where you have so much to do. stuff flying at you at weird times that you just have to take care of. Um, it can be hard to make sure that you’re getting things done on a daily basis and things can start to pile up on you, which is not what we want, right?

That starts to feel just stressful, energetically, like there’s this weight of all these notes on you. And that kind of stress can really, uh, over time contribute to feelings of burnout and overwhelm that are not good for anyone. So we want to avoid that for sure. But also, if you do have a big day, I mean, if you’re in a situation where you’re seeing eight, ten clients a day, especially like if you have shorter, um, meetings and you only have one time each day for notes, it can be harder for you to remember the details of each appointment.

Um, it can be more challenging, I think, for you to be thoughtful about what you’re doing with your notes in that period of time, because you’re not trying to do one of them, you’re trying to do like nine of them. So I think that that is something to consider. And then certainly another strategy is to do notes in between your sessions, the short break method.

And so what this is, is when you just have a little bit of time, 10 to 15 minutes in between each session, when you’re good about. Stopping your sessions on time and scheduling that time for yourself in between each session. Then you have, you know, three minutes, five minutes to quickly do your notes, record it, post it, it’s done.

And that, you know, can be really, really helpful, similar a little bit to concurrent note taking. I mean, it’s right after the session, so it’s still fresh in your mind and you’re still doing it right then and there, which means that it doesn’t pile up, which is the ideal. So that can be a really good, um, System for many people, but it does require your ability to hold firm boundaries so that you have enough time between your sessions, um, which it can be, you know, a professional growth opportunity for many of us in and of itself are spending sessions on time, not running over right, not going back to back to back all day.

There’s that. Um, and also, you know, if you have other stuff that comes up, if you need to eat lunch or go to the bathroom or have to field a phone call, then all of a sudden, you know, you now need to do that note another time. And so do you try to do two notes after your next session? Or if, you know, You miss a couple and you aren’t also in the habit of time blocking, then all of a sudden you have to find time to do a few and that can, you know, start to turn into a stressful experience as well.

So always pros and cons there, but between sessions. does work well for for some people. But the goal here is really to find a system that works for you. I mean, every clinician is different and every day is a different day. I’ll also tell you that I think to have some kind of a hybrid, um, Flexible approach to this really does work.

Well, well, my preference is to do concurrent notes. It is also true that sometimes I have had sessions where it’s really not appropriate for me to be typing while people are talking. We’re going into. Serious trauma work. There’s a lot of big emotions that are being processed. You’re right. I’m not sitting there typing while people are going into that.

And so there, you know, I will finish my notes right after that session is over. I try really hard not to be in a situation where I have to do a bunch of notes all at once, cause that just doesn’t work for me. However, that is really the best fit for some people. So thinking about what is going to be the best method for you, that is really just True for you.

You know, that’s always the way to go and allowing yourself to be flexible with that. But I will also share a different idea here. And this is something that, um, I think it has been really, really helpful for me over my career. And that I, Love to share with you. And this actually goes back to a really early professional experience of mine.

One of my very first supervisors who was a phenomenal supervisor. When I would do my case notes and documentation, she would always challenge me, meaning like she would actually not sign off on my notes until I additionally added my. Current case conceptualization to my notes, which was over and above, you know, the subjective, the objective, the assessment, the plan.

Um, you know, it was deeper than that. It was challenging me to in one or two sentences, write down what my understanding of the problem Really was and what my plan was for how we were going to move this and this is really hard to do, particularly if you’re not using your notes as an opportunity to synthesize a case conceptualization.

And so even when I’m doing notes concurrently, or right after a session, certainly, you know, if I take more time, I am always challenging myself to make my notes be a deeper experience for me that helped me do a better job as being a therapist or a coach. Because of my case conceptualization, and as I’ve talked about on other episodes of this podcast, when clinicians get stuck, when they feel overwhelmed or like, you know, things aren’t working in their work, the way that they hope it to nine times out of 10, it’s because they don’t have a clear case conceptualization, or the case conceptualization that they’re operating from is not a Actually accurate when there’s a disconnect between what you think is happening, or if you don’t really know what’s happening and what’s going on in the room, you’re going to get stuck.

And so the whole idea here is to totally reframe what you are doing. Doing with case notes and with documentation, framing it as not this chore, this task, this thing that I simply have to do because it’s my job and like feeling that, but really think about it instead of here is my small moment to get the kind of clarity that I need about this.

This client and this situation so that I can be the kind of guide and leader that this client needs and deserves that turns the act of doing case notes into something really different. And I don’t know about you, but for me, if I hold on to that mindset, it helps me stay, um. More present with the notes itself and really, like, stay on top of it because it’s not just a task that I have to cross off my list.

It’s turned it into this really Vitally important piece of what needs to happen in order for me to have the kind of clarity that I need in order to do a good job. So I just wanted to throw that out there as a bigger picture advantage and just way of thinking about this. It can really improve your entire process.

Now, I also want to add something that you may or may not have thought about before, but it’s very much on my mind, especially as I am doing clinical supervision or mentoring other clinicians in my practice here at Growing Self is really to be thinking about What is happening with your administrative pain points, because when we pay attention to how much time we are spending on documentation, it can really give us insights into what’s going on with actually really important things like our entire career or our work environment and having that self awareness can help us make sometimes pretty substantial changes to our work environment.

Like, like what we’re doing on a 10 year plan kind of level. And I know that sounds kind of crazy, but stick with me for a second. So there are different ways of operating as a therapist. And if you are a therapist who is doing a lot of clinical mental health right now, or if you are entwined with health insurance companies and third party payers, being mindful of the time that you’re spending.

Spending on paperwork is absolutely critical because there is a real cost associated with your time on administrative work that’s easy to not think about. And that’s related to this time versus earnings equation, which is why keeping track of your actual time is so important. Like, so for example, if you have one billable session that is 45 minutes long and that is the, you know, what you get paid for essentially.

And then you need to spend another hour or two on forms treatment plans that are very elaborate, detailed case notes, which, you know, if you are submitting, um, for reimbursement to a health insurance company, your case notes need to really be reflecting everything that’s in that CMS form saying that we are treating depression and here’s.

Here’s why. And here’s what we were focusing on. And here’s how, why, what we were talking about is in alignment with my treatment plan and with the amelioration of these depressive symptoms, et cetera, et cetera. I mean, you have to do case notes differently. If you have a diagnosis and medically necessary treatment, that’s, that’s part of the deal because health insurance can request to see those notes, right?

Additionally, if you know you’re on your own to be submitting claims for all your billable hours, that in itself can really take a long time because it’s the submitting of the claim and that it is getting the claim rejected and having to figure out why and having to do it again and like also the insurance company and it’s just, it can get to be ridiculous, but especially if you know you are in network with an insurance company and you may might be making, I don’t know, 60 or 70 an hour through that contracted rate.

You know, if you divide that by two or three. That’s You know, in terms of an hourly rate, it starts to get pretty low, especially if you’re on the lower end of that spectrum. You may be in a very real way, earning 20, 25 an hour, which could be fine, but it also might be a far cry from what you envisioned when you started your private practice.

Right? Um, and certainly even in an agency setting, if you are in a working environment where, you know, the requirements of the billing system or the, the, Process is draining in terms of how long it takes. Um, some agencies in my experience have their proprietary systems where, you know, their, uh, actual electronic records management systems are so clunky and just painful to use that it can take a really long time to be able to do your notes, which can really, um, add hours every day to your workload in a way that can really contribute to feelings of burnout.

And so I think that by paying attention to these pain points, like, yeah, how much time am I spending on documentation? It can give you visibility into, wait a minute, what am I doing? And is this what I want to be doing? Do I want to keep doing this? I mean, I have had clinicians decide to join our practice growing self coming out of agency environments or other practice situations.

Because of the fact that we don’t do anything with insurance companies, really, so that there’s minimal paperwork, I mean, above and beyond a case note, which is, you know, for the purpose of our own documentation and also getting clarity on what we’re doing with our clients, but you don’t have to worry about insurance forms or treatment plans or any of the.

You know, jumping through the hoops and that could be such a major pain point that people actually change working environments because of it, or for private practitioners to say, you know what, this medical model thing, getting paid by insurance companies, it sounds good, but when I think about the work required to actually make that happen, it would be better for me to actually get off all these insurance panels and figure out a different way to make this work.

Maybe I would be seeing fewer clients. But, you know, when I really figure out the, the dollar cost averaging, I’d be making about the same amount of money anyway, but either working the same or less. So that would be really helpful for me to reassess the practice model. And so I just wanted to share those with you.

I mean, if you’ve been drowning in paperwork for the privilege of earning as much as you would in a much less stressful career, let’s be honest, you know, I’m worried about, can I pay my student loans and all these things as might be time to consider other options, including cutting the. Cord with insurance companies, although I mean, I don’t want to oversell that because that can be a risky move to, uh, particularly if you’re in a business model where you are dependent on an inflow of clients coming through insurance company referrals in order to connect with you.

Because unless you have another solution for that, you’re going to have a new problem, which is now how do I connect with clients who don’t necessarily want or need medically necessary treatment and who are motivated to work with me and pay me out of my own pocket? pocket. So, you know, unless you’re careful with that, you can wind up trading one time drain for another.

On the one hand is documentation and submitting insurance claims. Or on the other hand, spending a lot of time, money and energy on marketing, right? Which, um, may not be your chosen profession either. So anyway, I just wanted to be a good friend to you and say that out loud that it can sometimes be this Or that for some people, a great solution is joining a group private practice with a strong marketing machine that handles, you know, client acquisition and also a strong administrative support and billing machine that takes care of the admin parts.

So that, you know, the job of a therapist is really to be there, to see my clients, to love that experience and then have all the rest of it be somebody else’s problem. You know, that works really well for some people. Although, I mean, even in that situation, you can expect to be paying practice management fees to somebody to handle all of those things for you.

So at the end of the day, the cost does have to come somewhere. Um, through some, I mean, these things simply have to get done, but. I think it’s important to be able to know what your options are and how these things work so that you can be making informed decisions around how you want to be spending your time and your energy and where you want to be spending your money.

Is it earning a lower hourly rate? Is it paying somebody else to do some of these things for you and maybe earning more per hour, doing more of the work that you want to do? I mean, those are all equations that everybody needs to reflect on, but. Figuring out your relationship to something as banal as paperwork can help give you visibility into that and help you make informed decisions around, you know, what you’re doing on a big picture level.

So I hope that those ideas about paperwork were helpful for you. We talked about some strategies, certainly for managing it all. But I think we also talked about some different mindsets, like how to look Add to the act of doing documentation in a way that may make it feel more meaningful to you. And also the way to pay attention to what’s going on with administrative tasks in a way that gives you more visibility into, you know, really like what you’re doing with your career and whether or not that’s a good fit for you.

So I hope that this was helpful for you and thank you as always for spending this time with me today. I’ll be back in touch with you next week with another episode of love, happiness and success for therapists. And in the meantime, take care.

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