If you’ve spent any amount of time in a therapy clinic, you’ll appreciate the importance of a thorough case note. For accurate recall, tracking treatment and effective collaboration, these notes are absolutely indispensable. But are your therapy notes being written to their fullest potential?
To make any therapy note effective and useful for insurance purposes, we recommend ensuring yours contain these 10 essential elements:
1. Demographic Information
Start off with the absolute basics. This will cover the client’s sex, race and age, as well as employment and relationship status. What is their current living situation? Are there any pertinent details about their occupation you can include? Any objective and basic information here can provide valuable insight for diagnosis and treatment.
When documenting a client’s main complaint, it’s very helpful to record as much as you can in the client’s own words. Paraphrasing or summarizing may be more efficient in the moment, but when reviewing notes later, being able to find important subtext in how a client expresses their complaint can make for very beneficial guidance.
Your clinical assessment of your client’s reactions and suffering plays a vital role in diagnosis, so be meticulous when recording this. A very thorough breakdown of what a client admits and denies needs to be your solid foundation for this element of your therapy note.
4. Safety Concerns
If your client makes any comments or suggestions that could lead to self-harm, make sure to document them very accurately here. This can help provide background for any urgent intervention by other professionals you feel may be necessary.
With the myriad of ways pharmaceuticals can have an effect on a client’s mental health, it’s important to pay close attention. Make sure to keep this section updated and ask your client regularly if anything needs to be added or pulled from this list.
6. Symptom History
What is the full history of your client’s struggle? Has it persisted through various jobs, relationships or life changes? What are the active measures they’ve taken over the years to address this problem? Have they had problems taking active measures? Have they acknowledged the need to address their problems but have been unable, or unwilling, to do so? Approach this from every angle to establish a very clear understanding of their struggle so far.
7. Current Mental Status
During your time observing your client, you’re reading between every line to get a handle on the current status of their mental health. This careful analysis will outline all relevant aspects, and it can be brief. Just make sure these notes are thorough enough to provide comprehensive insight down the road.
8. Narrative of Events
Include a detailed timeline of every interaction with, and related to, your client. These should be time stamped to show specific actions and specific times. You’ll want to include appointments as well as why they were scheduled, any missed appointments and calls for any outside intervention.
9. Session Recaps
Summarize your sessions with a brief recap. Two formats, SOAP and PAIP, are common for this element of your notes. Follow either of these acronyms for efficient synopses:
SOAP — Subjective, Objective, Assessment, Plan
PAIP — Problem, Assessment, Intervention, Plan
10. Discharge Summary
Your final summary will provide a quick review of your client’s association with your practice. This will provide a short review of their demographic info, their initial assessment, therapy targets and plans, any necessary interventions and follow up work.
By diligently breaking your notes out into these focused sections, you’ll be providing yourself with a much more comprehensive and easy to search note for better recall. You, your team and your client’s insurance company will all be able to work more efficiently, saving time and headaches for everyone going forward.