By Mali McAnarney, Master of Counselling
Whether in your practice you diligently write your notes up after each session, or you consciously attend to them at the end of the day. Or maybe you like to scrawl a few hand-handwritten notes with the ‘I’ll get back to that later’, or you’re using your well-deserved and highly anticipated coffee break to alas…write your notes. Or you may be none of these examples, but let’s face it, we all have to do them. There is no right or wrong in how you attend to your notes (except if you don’t do them of course!). Best practice will tell you to attend to them in a timely manner but each clinician’s interpretation of this will be in the capacity of what works for them. But how often do you think when you are writing them; would these notes help or hinder me? And importantly would they help or hinder my client?
Stay organised
How clinicians format their notes is, by all means, a personal and clinical preference. You might be using SOAP notes (Subjective, Objective, Assessment, Plan), or DAP (Data, Assessment, Plan), or BIRP notes (Behaviour, Intervention, Response and Plan) are you sick of the acronyms yet? However you choose to document your notes, at the root of what is important here is that they are clear, concise and specific. Forget the frills and fluff.
It can be a very fine balance between having comprehensive notes that provide a clear picture and adding unnecessary detail. If you can get the same picture in less words- opt for less words.
How you choose to structure your notes is up to you but the key to staying on top of them is to stay organised. Find a format that works for you and stick to it. A structure, whether it is one of those acronyms above (or some other one) or maybe you have developed your own best-practice structure but whatever it is, if you stick to it then it will help you steer clear of the unnecessary rabbit-warrens we could find ourselves down while we are writing and reflecting, what did my client mean when they said that?
Don’t leave it to chance
Of course, be factual, leave the emotional soap operas to your commentary on your favourite reality television show. If you ever re-read something and wonder, was that too much? The chances are that it was. Leave it out. Replace all those words like ‘seemed’, ‘appeared’, ‘gave the impression’, ‘showed signs of’; what they do is they automatically give your judgement. If something is worth commenting on stick with the facts, instead of writing “they appeared frustrated when they spoke about their mother,” replace it with; “they clenched their fists and raised their voice when they spoke about their mother.” This way your description is purely observational and unbiased as it is exactly what happened.
Less is more
That old chestnut, less is more. Well in the case of notes it absolutely can be. You don’t want critical information, like suicide ideation, self-harm, domestic violence; lost in a sea of wish-wash. Be direct and you will find that your notes automatically become succinct. On top of that you will thank yourself when you go to re-read your clients notes before their next session whilst juggling the other six sessions you have back-to-back. Avoid the jargon, be real, remember your client is allowed to access their notes any time they would like and if you have spent all those hours of dedication and time with them- the last thing you want to do is confuse them.
It’s sensitive information
We should all know this so let’s not go over this too much. We all know notes are confidential. Just stating the obvious to make sure it’s covered. We all know that feeling.
Notes in the new era
With the development of AI, clinical case notes and how they are documented are becoming ever evolving. You choose. Currently there are many case-management systems that are beginning to provide AI options. This attractive option not only appeals to your time-management brain but they could be more accurate, they could mean that your more present with your clients instead of trying to summarise in your head that important detail they just said so you can bank it for later as it’s obviously going to be critical information and not part of the wish-wash… But do your research first and importantly ask your client for consent. That way you can maintain an ethical practice.
So, let’s reflect
After reflecting on your own note taking practices ask yourself the question do your notes help or hinder?