General guidance for documentation

General guidance for documentation:

Do not make assumptions – if you suspect something, your opinion must be substantiated. If you do not know something, or cannot remember, do not write it.
Understand the purpose of the record – If an intervention or clinical judgement was not documented, it was not rendered.
Don’t rush – take your time with your case notes. Include information that is logical and relates to the plan of care.
Don’t overdo it – Enter only the information that is pertinent to the client’s situation and then stop. The client’s record should be a logical short story. It begins with an assessment and moves to a plan, session notes, and finally, termination. In general, if an entry doesn’t relate to the problems listed in the most recent plan or review, it is not necessary.
Write the facts, not opinions – Write legibly and organise your thoughts before you write them. Eliminate unfounded opinions and maintain current records.
Be clinically informed – When making an estimate or expressing an opinion, label the entry as clinical opinion or diagnostic impression.
Keep the emotion out of it – Your personal frustrations with clients can be easily seen in the case notes, and it says more about the practitioner than the client. For example, “John was more cooperative than expected” clearly denotes the frustration with the client.
Be kind – words can be hurtful. Always write the case notes expecting the client to read them and avoid criticism and labelling such as stupid, fat, lazy, boring, etc. Involving the client in the documentation process is courteous and promotes empowerment.
Be objective – use words that precisely describe behaviours and not subjective interpretation. Saying “the client was not interested in the session” is an opinion; you cannot assume you know the intent of the client. You can write in the observation section, “Client was yawning and looking at their watch multiple times in the session” or “Client repeatedly asked if the session was over” to describe the specific behaviours.
Be professional – Write with professional authority. Be concise, consistent and specific. If you are too vague, it can be mistaken as incompetence. Back yourself with your clinical opinion and treatment plan.
No take backsies – Once it is written, it is often difficult or impossible for it to be unwritten. The goal should be to minimise the amount of information included in our session notes with the aim of meeting a client’s desired outcomes. As little as possible without losing relevant information. Re-writing notes or changing or removing information with the intention of preventing disclosure is an offence.

Let’s consider more examples taken from the ACA guidelines:

A favourite but inadequate phrase in records involves ‘negative attitude’. Again, that is too vague and too judgmental. To make it clear, write something like: ‘learn to discuss problems instead of throwing things’.
A frequent goal is ‘improve hygiene’. That’s too vague because it doesn’t tell you enough of a story. You must be specific. How about: ‘brush teeth and shower each day’?
Don’t write: ‘learn to become more independent’. What does that mean? Set up a business? Leave a husband? The specific goal could be: ‘get up in the morning and report to job on time’.
‘Increase self-esteem’ is another favourite goal, but it’s difficult to really sink one’s teeth into such a phrase. How about: ‘will not be critical of self or personal decisions about disciplining children’. See the difference?
The record may read: ‘client participated in chalk talk’. What does ‘participated’ mean? Will every reader understand that a ‘chalk talk’ in this instance is a chemical dependency lecture? Did the client talk? Cry? Take a swing at another client? Or at you? Someone can participate in an active or a passive way. So one word doesn’t tell much. To clarify ‘participate’, add for example, ‘client revealed examples of how he had fooled himself about the increasing use of drugs. He reported denying the importance of wife’s complaints. The group encouraged his willingness to open up.’
Since part of our topic concerns communication, let’s take the phrase ‘communication problem’. Again, what does this mean? Why not list the exact problem; for example, ‘stuttering’, ‘speaking too fast’ or ‘talking around the subject’.
Is your client withdrawn? How do you know that? Write instead, ‘Suzanne is withdrawn as evidenced by the fact that she spends all her time in her room and refuses to even eat meals with her family.’
To characterise someone as ‘aggressive’ is not enough. Does the client fight? Push? Scream? Kick? Do not leave room for interpretation. If the client described eventually takes you to court, the term ‘aggressive’ used alone could be interpreted by the attorney as a positive characteristic, not a negative one.
If a client is unemployed, there may be more to the situation. Clarify your entry by adding something like ‘has been fired from last three jobs for drinking and excessive absences’.
You can define the term ‘nervous’ by writing something like ‘not eating; sleep is not restful; screams at children’.
Instead of ‘feels bad’, write ‘history of high blood pressure and heart condition’. Remember: one can feel bad physically and/ or emotionally. That holds true for another one-word problem: health. Enter something like ‘asthmatic condition requires expensive medication, so the client does without’.
When the client is ambivalent, you need to know why. So does a record user. Enter something like ‘She cannot make a decision about continuing in a marriage with an abusive spouse’.
We often think we are describing a behaviour when we say, ‘Henry is lazy’, or ‘Laura is aggressive’, or ‘Karen is withdrawn’. These statements do not describe behaviours; they make undefined judgmental observations. That could be disastrous for a supervisee and the agency. What characteristics or symptoms give you cause to think the way you do? Write them down!