Collaborative Documentation: Talking with Your Client About Engaging in the Progress Note Process

intakeAs mentioned in previous posts, collaborative documentation is a new approach to the way in which counselors produce their clinical documentation.  Simply put, the clinician “collaborates” with the client when it comes time to write the progress note.  Although there are definite benefits to doing this, counselors need to think about how to introduce this concept to their clients.

I have found that my clients have viewed me as “the expert”.  Usually clients are looking to the clinician to determine what they need to do to function better, to feel better, and to be better.  This, of course, is reasonable as the client is paying for the service the counselor provides.  Given this, clients may be confused (and even frustrated) if the counselor asks them to be a part of the progress note-taking process.  (After all, isn’t the client paying the therapist figure out what to do?).  Clients may also be unhappy about giving up some of their therapy time to stop, reflect on the session and have the counselor write the progress note.  Therefore, counselors need to be mindful about how they ask their clients to be involved in the collaborative documentation process.  Following are a few suggestions for how to talk with clients about this.

  • Explain to the client that you, as the counselor, want to provide the best care possible. Given this, you want to make sure that you are clear about what the client thinks, feels and experiences during the therapeutic session.  To best do this, you want to spend the last 10 to 15 minutes of each session going over the highlights of the work the two of you did together.
  • Also share with the client that therapy works best when the client is engaged in his or her treatment. Collaborating on the notes that you take will help ensure that you and the client are “on the same page” as to what is working and what is not working during the therapy sessions.
  • Another reason to engage in collaborative documentation is so that you, as the counselor, can gain further insights about what the client needs to move forward or make progress in therapy. The goal of counseling is to work with the client so that skills are gained, insights are realized and functioning improves, so taking time to reflect on what transpired during the session can help you both discover the interventions, tools and processes that have the most positive impact on the client.
  • A fourth reason to use collaborative documentation is to empower the client. Having the client process what she or he experienced during therapy will help the client realize the progress she or he is making and will enhance the insights gained.  The client may be able to leave the therapy session with a sense of direction, a feeling of accomplishment and a deeper understanding of how counseling is working for him or her.

It may take a while for a client to get accustomed to engaging in this type of reflection with the counselor at the end of a session, but more than likely this will strengthen both the therapeutic alliance between the client and the counselor as well as help the client move through therapy with more success.

Stay tuned for how to use an organized, step-by-step method for your collaborative documentation approach.  Having a system for how to take progress notes will help both counselor and client use the last few minutes of the therapy session in an efficient and effective manner.

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Considerations for Collaborative Documentation: Before You Start

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Collaborating with the Client: A Different Way to Take Progress Notes

I recentliStock_000001095739Smally attended a conference in Sioux Falls, South Dakota where one of the attendees shared with me a new way of taking progress notes that involves the participation of the client.  “Collaborative documentation” is the term for this type of note-taking process.  This is a person-centered activity that involves the client in the planning and reflection of their treatment.  I am reading the research and gathering more information about this form of documentation and will spend the next few blogs talking more in depth about this process.  However, think about this first:  Have you ever wondered if your client had the same perspective on what happened in the counseling session as you, the counselor, did?  What do you think would happen if you found out what the client was thinking about the work in which you both were engaged?  I can understand if, as the professional, you might feel a little vulnerable about getting this type of feedback from your client.  Even considering this may be a drastic change from how you have seen your relationship with your client and how you have approached therapy.  It would mean, to a certain extent, that you may have to be a little vulnerable (in the beginning) with your client when you ask for their feedback and get their view on what they experienced during the counseling session.  But there is a way to do this type of collaborative work with your client, and I want to talk you through the steps to do so.  Therefore, in anticipation of the next blog post, I ask you to consider this:  Would you be willing to engage your client in the treatment process more if it meant your client may show improvement in functioning at a quicker rate with a higher level of commitment to change?  Just think about that, and stay tuned for how to start incorporating collaborative documentation into your therapy sessions.

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Counseling Clients Session to Session: Summarize to Strategize

I have often found thiStock_000002528747Smallat a lot can be shared by a client during a counseling session.  Sometimes it is even difficult for me to summarize what WAS discussed!  However, I have found it very important to implement a few strategies both during and after the session so that I can keep therapy flowing in a positive, thoughtful manner from session to session.  Following are two suggestions that I hope other counselors may find useful in their work with their clients:

  • Summarize at the end of the session with the client. Within the last 5 to 10 minutes of the session, make a summary statement to the client and check in to see if the client agrees with what you have observed, heard and thought during the session.  Example: “Eileen, I could tell you were very upset today when you first came in given the conversation you had with your mother a few days ago.  It sounds to me like you are willing to work on establishing some better boundaries with your mother, especially since we have identified that one of the main reasons her comments upset you so much are based on your feelings of inadequacy in her eyes.  Is there anything else you would like to add to what I just shared?”
  • Once the su
    mmarization is confirmed with the client, propose what the focus of the next session will be or consider assigning homework for the client to do before the next session. For example: “Eileen, it sounds like we need to talk further about how to set some healthy boundaries with your mother.  Possibly next time we can discuss this further and even role play what you can say the next time your mother calls you.  Before our next session, would you be willing to write down at least three things you would like to say to your mother the next time she calls and starts asking you questions that you feel are intrusive?”  Check in to see if the client is amenable to your suggestions.
  • Once the client leaves, jot down on a notepad (or type into your computer/progress notes) some key words regarding the summary and the suggested therapeutic activity for the
    next session.

There may be times when it is not clear what the client wanted to focus on during the session.  If you h
ave difficulty thinking of a way to summarize the session, ask the client in the last few minutes of the session, “If you were to summarize what happened in our session today, what would you say?”  Listen to the client carefully to see how they respond, and then make connections between their summarization and what you either heard the client say or observed the client doing during the session.

The goal is to keep the therapeutic process flowing in a semi-structured, productive manner so that each session continues to move towards improvement in the client’s functioning and the realization of the client’s goals.  Ending each session with a summary helps the counselor write a better progress note and helps with the formulation of counseling interventions.  It also confirms with the client that you both are “on the same page” in regards to the work the client is doing and the goals the client is accomplishing.

For those of you using the STEPs method for your progress notes (www.stepnotesinc.com), jotting down the summary statement and the proposed activity for next session will help you write a more com
plete progress note.  Elements of the summary statement can be applied to the subject (S), the theory and the therapeutic interventions used (T), and also inform your evaluation (E) of the client.  The proposed activity or the in-between session homework is information to note in the plan (P) portion of your progress note.

As counselors, we want to see our clients improve.  Summarizing the session and strategizing for the next appointment helps counselors and clients build connections between session.  These connections, in turn, will keep the therapy process flowing, and our clients will experience rewards from the therapeutic work they do and the insights they gain.
If you would like to learn more about the STEPs for taking progress notes, visit www.stepnotesinc.com and watch the educational presentation at http://www.stepnotesinc.com/The-Presentation.

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The “P” in the “STEPs” to Taking Progress Notes: PLAN

goals-plan-puzzle-words-concept-56526424(1)This is the fifth and last in a series of five blog posts designed to inform counselors about the STEPs method for taking progress notes – a method that is systematic, efficient and effective.

The fourth step in the STEPs format for progress notes is the “P” – the PLAN section of the progress note.  The “plan” establishes continuity between sessions and context for upcoming sessions.

Counselors want to make sure they have a “plan” so that they can refer back to their notes before they see their clients again and be reminded of what they need to focus upon for the next session.  The “plan” refers to the short and long-term goals developed during the course of the therapy, with the central objective being the improvement of the client’s well-being. Plans can include homework, interventions, and goals. Plans can also include topics or other details that were not discussed during a session or statements the client made during a session that need further follow-up. Counselors should develop plans that ensure clients are striving towards and meeting short and long-term goals in a focused manner. Plans will vary from counselor to counselor, depending on the counseling approach and style. For example, a cognitive-behavioral therapist may use different types of homework assignments than those of the practitioner who employs narrative counseling techniques.

Thinking back to the case study of Samantha (see earlier blog post from November 30, 2015 at https://drrhondasutton.wordpress.com/2015/11/30/the-s-in-the-steps-to-taking-progress-notes-the-subject/), it will be important to identify homework assignments that focus on building her support system, improving her communication skills with her husband, and learning more effective parenting skills to use with her children.  Other goals may focus on increasing her self-esteem, engaging in activities that diminish her depressive symptoms, and using tools to cope with anxiety.  In the “Plan” portion of the STEPnotes, the Samantha’s counselor may use statements such as:

  • Samantha will utilize assertive communication tools she has learned in counseling to express to her husband her desire to spend more time with him and to have him be more involved in the raising of their children.
  • Samantha will integrate parenting skills, discussed in counseling, to more effectively manage the discipline of her sons.
  • Samantha will practice mindfulness techniques to cope with anxiety.
  • Samantha will decrease depressive symptoms through exercise and improving her sleep schedule.
  • Samantha will increase her support system by going to church, getting involved in volunteer activities there, and joining the book club in her neighborhood.

More information about the “Plan” portion of the STEPnote as well as suggestions for how to write goals are available in “The Counselor’s STEPs for Progress Notes: A Guide to Clinical Language and Documentation available on Amazon at:  http://www.amazon.com/Counselors-STEPs-Progress-Notes-Documentation/dp/1514643588/.  The STEPnotes downloadable forms, which can be stored on your computer or the PDF can be uploaded into your EHR, provide sentence stems to outline goals in the “Plan” portion of the progress note.  Examples of sentence stems are “client will change”; “client will decrease”; “client will exhibit” and “client will implement.”  The PDF form offers over 30 sentence stems for this part of the progress note.  These forms are available for mental health, school and career counselors and are at:  https://www.stepnotesinc.com/PDF-Forms.  PDF forms for both adult and adolescent/child intakes are also offered.

The STEPs were created to help counselors have a structured and professional way to document their work with their clients.  The format offers a streamlined method to write progress notes by detailing the subject, symptoms, therapeutic tools and interventions, evaluation and plans for clients.  Those who use the STEPs can keep better track of the progress of their clients, identify what is and is not working well in therapy, and be able to review their notes quickly before each session so that they can be better prepared to work with their clients.  STEPnotesTM provides the organized format for progress notes which indicates to both mental health professionals and those outside of the counseling field the importance and the value in the work undertaken by counselors, therapists, social workers and other mental health practitioners.

 

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The “E” in the STEPs to Taking Progress Notes: Evaluation

Sad woman speaking to her therapist while she is taking notes

This is the fourth in a series of five blog posts designed to inform counselors about the STEPs method for taking progress notes – a method that is systematic, efficient and effective.

The third step in the STEPs format for progress notes is the “E” – the EVALUATION section of the progress note. Evaluation involves a few different areas regarding the client’s diagnosis and progress in therapy.

First, it is important for the therapist to assess the client’s level of engagement in therapy.  In the “E” section of STEPnotes, this would mean selecting options such as the client being engaged in therapy, open, guarded, minimizing or stuck.  The goal with this part of the evaluation is to ascertain if the client is working towards their counseling goals or if something is occurring that inhibits the counseling process. Also, does the client’s response to therapy change with each session or is the client relatively engaged in the same manner each session? This part of the STEPs reveals the type of relationship and trust established between the therapist and the client. The therapeutic relationship is a central component to successful counseling. If a client becomes unengaged or guarded after having exhibited trust towards the counselor it is vital to note when this occurred and discovering, if possible, what caused the change in the relationship. Once trust is established, the counselor can work effectively.

Other issues regarding the evaluation of a client’s engagement in therapy are related to the client’s level of functioning. For example, a client may have difficulty engaging due to psychosis, a medical condition that exacerbates cognitive problems, or a lack of mental capacity. This section of the STEPs helps the counselor identify critical aspects of the counseling session, which in turn allows the counselor to establish future counseling needs and approaches.

EVALUTION also needs to include an assessment of the client’s current level of functioning.  STEPnotes has developed a scale that runs from 1 to 10, with 1 being very poor functioning and 10 being optimal functioning. For example, a client who comes to therapy and appears disheveled, has difficulty expressing thoughts, and has not been to work in the last three days due to delusions is more than likely at a “1” or a “2” on this scale. A client who has learned coping skills for anxiety, who has implemented these successfully for the past six weeks, and who is now able to attend social functions and engage in healthy relationships with members of his or her support system is probably at an “8,” or a “9”.   A client who is at the lower end of the scale may need more intensive or even in-patient treatment. A client who has moved up the scale during the course of therapy to a “9” or a “10” is more than likely at a point where therapy can be reduced or, if appropriate, concluded.  Recognizing the level of care a client needs is important in the overall evaluation, and this scale provides not only a quantitative designation of the client’s current level of functioning but also an assessment of the client’s current level of therapeutic needs.

The last part of the evaluation section refers to the DSM-5/ICD-10 diagnoses.  Diagnoses for clients may change over the course of counseling as counselors gain new information about the person they are seeing in therapy. If a diagnosis does change, then the counselor may need to modify the treatment plan and counseling goals.

Thinking back to the case study of Samantha (see earlier blog post from November 30, 2015 at https://drrhondasutton.wordpress.com/2015/11/30/the-s-in-the-steps-to-taking-progress-notes-the-subject/), it will be important to see how engaged she is in therapy or if she remains stuck in her patterns of behavior.  As her counselor, you will want to see if she is willing to set goals and, if so, does she work towards them?  Also, the “E” part of your notes for Samantha will show how well she is functioning (more than likely she was at a “4” or “5” early on in therapy), and following documentation in this section will show if her level of functioning improves, stays the same, or declines.  If Samantha’s functioning does improve, it means therapy is working.  If it does not, then counseling may need to take on a different approach or incorporate different therapeutic interventions.  Also, her diagnosis will need to be more carefully assessed in terms of her anxiety and depression.  For example, are her symptoms due to more of what is happening at this time in her life (recent move, husband traveling a lot, sons getting older and needing a different form of discipline)?  If this is the case, the symptoms may be more closely aligned with an adjustment disorder.  If the depression and anxiety persist, despite attempts she makes to improve different areas of her life, then the diagnosis or diagnoses may need to change to reflect the persistence or seriousness of her symptoms, thoughts and behaviors.

The “E” portion of the STEPnotes provides guidance for counselors in terms of how the therapy is going and how well the client is functioning.  The “evaluation” part also is the place to indicate if there is suicidal or homicidal intent or other forms of thoughts or behaviors that indicate a need for a different level of mental health care.  This is an important part of the progress note in that it reflects how well the current level of care, the counseling approach, and the goals are helping the client.

More information about the “Evaluation” portion of the STEPnote is available in “The Counselor’s STEPs for Progress Notes: A Guide to Clinical Language and Documentation available on Amazon at:  http://www.amazon.com/Counselors-STEPs-Progress-Notes-Documentation/dp/1514643588/.  The STEPnotes downloadable form, which can be stored on your computer or the PDF can be uploaded into your EHR, provides options for the evaluation of client’s progress as the well as “Assessment of Client’s Functioning Scale”; this individual counseling note form can be found online at:  https://www.stepnotesinc.com/Store.  Next post will focus on “P” part of the STEPs; stay tuned!

 

 

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The “T” in the STEPs to Taking Progress Notes: THERAPY TOOLS

This is the third in a series of fiviStock_000002528747Smalle blog posts designed to inform counselors about the STEPs method for taking progress notes – a method that is systematic, efficient and effective.

Remember Samantha from the November 30th blog post?  This fictional client was anxious, overwhelmed, depressed, lacking in self-esteem and making poor choices.  The first part of “STEPs” – SUBJECT(s) and SYMPTOMS – focuses exclusively on the client.  The “T” in the STEPs method focuses on what you, the counselor, do during the course of the session.  “T” refers to the therapeutic tools you incorporate to help the client move towards her or his goals and improved levels of functioning.

When using the STEPs format for progress notes, you first will choose the types of therapeutic approaches you use with the client.  In the case of Samantha, you may want to choose cognitive-behavioral therapy to deal with her feelings of depression and anxiety, reality therapy to address the issues she is having with her husband and with re-engaging with a former boyfriend, and person-centered therapy to continue to show nonjudgment, to build rapport and to demonstrate unconditional positive regard.

In addition to the therapeutic approaches, this part of the note is very important as it breaks down more specifically what you, the counselor, did during the therapy session.  Action verbs are used to start sentences to show the counseling skills and techniques you utilized to assist the client.  Using the case study of Samantha, you may write sentences such as:

Acknowledged the many concerns and feelings Samantha was currently experiencing
Addressed
Samantha’s concerns about the upcoming visit with her in-laws
Asked Samantha the “miracle question” regarding her marriage
Demonstrated ways to improve communication with husband using assertive techniques
Evaluated realistic goals regarding the online communications with the ex-boyfriend
Explored Samantha’s issues with her self-esteem and when negative self-talk started
Guided Samantha through a role play of disciplinary parenting techniques to use with her sons
Identified two goals for Samantha to pursue in the upcoming week to improve functioning
Reflected on strengths Samantha has used recently with moving to a new place, making adjustments
Reframed Samantha’s negative self-talk about not being “good enough” for husband’s family

The “T” section in STEPnotes shows what you have done and further helps to establish what is and is not working in therapy.  (We will talk more about evaluating the counseling approaches and goals in the next two upcoming blog posts).  Keep in mind that this section also shows third parties the work you have done as a counselor; these third parties may be insurance companies or legal entities should they request a copy of your progress notes.  What is always important to keep in mind is that you keep your progress notes objective and factual.  These are records that may be open for third party review, so you will want to document a neutral account of what occurred during the therapy session.

Should you want more suggestions for action words or more details regarding the STEPs for taking progress notes, read “The Counselor’s STEPs for Progress Notes: A Guide to Clinical Language and Documentation” available at: http://www.amazon.com/Counselors-STEPs-Progress-Notes-Documentation/dp/1514643588/.  The book contains over 60 action verbs to help counselors write sentences that clearly document the counseling skills they used with the client.  If you want to be more organized with your progress note format, consider using the downloadable, “offline” forms at www.stepnotesinc.com that can be uploaded as PDFs to your existing EHR system or stored on a secured computer.  Once purchased, you can use the offline forms as often as you like for your progress notes (and intake note formats for both adults and adolescent/children are also available as downloadable forms).

Stay tuned for more information on the “E” and the “P” parts of the STEPs, using the Samantha case study, so that you can use the STEPs for your progress note needs.

 

 

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