The purpose of session notes

Statistically speaking, the likelihood of you being taken to court for malpractice is very unlikely, but it is highly likely that you (and your records) will be brought into court for custody disputes, work decisions and other situations of the like. In Australia, very few counsellors and psychotherapists are successfully sued or lose their registration. This lesson is not designed to scare you, but to prepare you to have the best practice when it comes to documentation to protect you if you ever need it.

What is the purpose of case notes? Is it to remember what you said? To be the bane of your existence? To not get sued? Understanding the why of case notes helps us to get a better understanding of why it is so important to document effectively.

The purpose of session notes:

To help remember stuff

To support us in recalling accurate and relevant client information and assist us in understanding the client’s needs and concerns. It is to support with the connection to the client and show them that you care about their situation. One quick way to lose client trust is to forget things that they have told you. Re-reading your notes before the session can help you remember their situation and to follow up with any homework you have allocated them.

Continuity of care

Case notes allow for uninterrupted continuity of care if another practitioner sees the client. They also allow us to represent the client’s concerns and needs whenever required by another person, for example, if a referral becomes necessary or in the case of a court subpoena.

To protect ourselves in court

In the courtroom, your counselling records can be manipulated in ways you can not even begin to imagine. If you have missed entries, incomplete forms and altered documentation, you are leaving yourself vulnerable in the legal system for your work to be called incompetent. Session notes provide protection from professional liability. Accurate, clear and factual session notes help to protect us from complaints made against us or in cases where a client’s recall significantly differs from ours.

To process the session

If you have had a challenging session with a client, writing your case notes can support you to go to a deeper level of observation and to process anything that you may have missed. It supports you in reflecting on the session and making well-informed decisions away from any triggers that may have arisen during the session. It brings a deeper level of healing and care to the client the more we are able to observe what is going on for them in a detached and non-biased way. The deeper the observation, the greater the clarity.