Clinical documentation….Ugh!! Just hearing the phrase makes my head sleepy. As therapists, why should we care about clinical documentation? I often hear, “I just want to help my clients; I hate paperwork.” I had supervisors tell me that clinical documentation is the only way people know about all the hard work we do behind our closed doors (or computer screens). Documentation is a bill, an accurate account that we provided a service to our clients that was meaningful and medically necessary.
Have you heard of the Golden Thread? This is a helpful phrase to keep in mind when documenting client interactions. The diagnosis, the progress note, and the treatment plan should all link together, hence the word “golden thread.” Here’s an example of using the Golden Thread in your clinical documentation with an adult outpatient client:
Diagnosis Example: Generalized Anxiety Disorder
Treatment Plan Goal Example: Client will use his strength of determination to practice coping skills and self-care at least 2 times in between therapy sessions to decrease anxiety symptoms.
Treatment Plan Objective Example: I want to go yoga class 2 to 3x a week because of how relaxed and confident I feel after a work-out.
Progress Note Example:
Clt presents with less anxiety, as evidenced by self-reports of feeling calmer in his body and by less reports of worry in session. Clt went to the gym 2 times this past week and reports on how this feels like a “release.” Client is also recognizing cognitive distortions most days. He states that ruminating thoughts have deceased before bedtime on days that he attends yoga.
Many clinicians struggle with what “needs” to go into a progress note. The meat of a progress note is what the client reported, how they presented and what you saw. For best practices and legal reasons, it is best to keep the wording simple and not too detailed.
Here is an example of too much information in a progress note:
Client reports that his father visited and was “very emotionally abusive.” Father told him that he was “too sensitive and too tightly wound.” Father did not help clean up after himself, so client felt more overwhelmed, as he was trying to study for his midterm exams. Client says his anxiety increased and is feeling that he tried some coping skills, but they did not always work. The worst experience this week was that his cat was sick. Client had to take him to the vet and it was expensive. Client is stressed about this and does not know what to do. He was having a difficult time in session when discussing his week and became more agitated. We practiced an over energy correction exercise in session. Client became more relaxed and said “I wish I could remember to do this on my own but it is so difficult.” He was able to use a balancing statement of “you got this.” We talked about that and how to remember coping skills independently. Client shared that he found this helpful.
Here is an example of just enough information in a progress note:
Client presented with increased anxiety, as evidenced by shifting eye contact and tight body posture, and shallow breathing. He reports an increase with anxiety this week due to several life stressors: midterm exams, family visit, and cat being sick. He shares about the difficulty of reaching for coping mechanisms independently. Balancing statements were somewhat helpful. We practice a relaxation technique in session, which he responds to well, as his body posture is more open, and he reports feeling more present.
Progress Notes
Whether you use SOAP notes or DAP notes or use another format, it is recommended not to use too many quotations. A few quotations with a phrase that seems “stuck” or common can be helpful but if you use too many, it is often not directly the clients’ words. Keeping your language clinical yet strength-based and person-centered is also recommended.
If your progress note template has a mental status exam section, it is important to fill it out. This can be simply checking boxes that the client is “presenting within their baseline” and reporting no s/i (suicide ideation) or h/i (homicidal ideation). Pull back with a lens of what is most important to record for clinical purposes. Clinical information linking back to the diagnosis and the treatment goals show a cohesion and an ability to track progress. The Golden Thread shows that during your sessions, you are staying focused on client-centered goals, and these goals link back to the diagnosis.
Treatment Planning
During treatment planning it is best to keep the goals related to SMARTS:
Specific
Measurable
Achievable
Relevant
Time bound
Strengths-based.
I like to use the Smarts format but also add clients’ direct words, using quotations for this.
Here are some examples of SMARTS Treatment Plan goals:
Client will identify anxiety symptoms & triggers and develop coping skills to manage these symptoms and will address this area in at least 2 sessions per month. “I want to learn more about my anxiety and ways to cope so my life seems more manageable.”
Client will decrease their GAD 7 score by 3 points over the next 3 months by understanding his triggers, learning coping strategies to manage, and using his strength of spirituality to help stay more connected to the present. “I know that I am an ambiguous person, and I want to use this to help me learn healthy ways to cope with anxiety every day.”
Make sure to allow enough time to complete your treatment plan together with clients. Treatment planning is an important step that connects to your client’s motivation for change—their buy in. Some helpful, client-centered questions to ask during treatment planning are:
What would you like to see changed or different in your life over the next 3 months?
What are you doing now to reach that goal?
What would you like to add into your life to reach that goal?
Learning How to Do Clinical Documentation
Clinical documentation can be a difficult and frustrating process to learn. Most importantly, be kind to yourself. Learning a new skill takes practice, so allow yourself space to grow. There are several Apps now available to help, or even treatment planners (e.g., Wiley Treatment Planner). Firelight Supervision offers once a month, inexpensive trainings to help prepare you in your clinical documentation journey. Having your supervisor check in on your documentation is also a necessary and valuable process. It’s okay to ask for help—you got this.
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Author Biography
Kristen Dammer believes in addressing the whole health needs of you as a person, and her dedication, creativity, and flexibility as a therapist are her greatest strengths. Her holistic approach to anxiety, grief and trauma helps you feel in control and creates a welcoming environment for you to share your vulnerabilities, fears, and experiences. She is trained in EMDR (Eye Movement Desensitization and Reprocessing) and uses it to treat anxiety and trauma. Follow Catalyss Counseling on LinkedIn, Facebook and Instagram.