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Life Hacks for Therapists: Mastering the Art of Case Notes and Documentation
Dr. Lisa Marie Bobby is a licensed psychologist, licensed marriage and family therapist, board-certified coach, AAMFT clinical supervisor, host of the Love, Happiness, and Success Podcast and founder of Growing Self.
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:
- Stay organized: Use digital tools or apps designed for therapists to keep your notes organized.
- 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.
- 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!
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