What’s one of the most common problems I see with students and recent grads? They have trouble getting their paperwork done! I’m the Quality Assurance Manager for a community mental health agency and it’s my job to make sure I give all our students and therapists the best tips and tools to make the documentation part of their job easier. I know, I know, you thought my job was to make their lives miserable, right?
As a student or a recent graduate you usually have external requirements for your paperwork. You have deadlines, you have people reviewing your notes, and someone else has likely chosen the template for you. If you’ve had multiple supervisors you’ve probably also gotten disputing opinions on how much to write and what should go where. But I’m sure you also got one overarching message- get your paperwork done on time!
Easy Tips for Timely Documentation
Here are some easy tips for getting your paperwork done on time. You can start using these right away. Warning: Not every method works for every person! Be disciplined about sticking with a method for at least two weeks and then evaluate whether or not it’s working for you.
1. Write in chunks. Some people are able to see a client for 45 minutes, write a 10 minute note, see the next client for 45 minutes, etc. If you can, stick to it and more power to you! Most of us aren’t able to do that, though. An alternative is to write notes in chunks. For example, see 6 clients on Monday from 11am-5pm and then spend an hour writing notes for all those clients. The time you select will depend on your schedule and flexibility, but try to keep it within 72 hours of your session so you don’t get backed up or forget what happened. When I worked at an agency I always scheduled assessments in the morning and made sure my afternoon was clear so I could finish it that same day (and then it was off my plate!). For regular sessions, I often saw clients in the late afternoon/evening so I didn’t want to stay until 8pm writing notes. I would schedule an hour or two in the mornings the next day and do all my previous day’s notes then.
2. Be consistent. Regardless of whether you write in chunks daily, every other day, or hourly you have to be consistent! Missing one day’s notes means adding an extra 60-90 minutes on the next day you come in. Find the schedule that (realistically) works for your lifestyle and then write it in your calendar. Documentation time has to be kept as sacred as a client’s weekly appointment time and your lunch break or you’ll always find other things to do.
3. Create a plan to catch up. If you do get behind in your notes (and most of us do, at some point or another), the workload can spiral out of control very quickly. Be honest with yourself and create a plan as soon as you notice the problem. A common mistake new therapists make when catching up is neglecting their current notes to complete the older notes. This keeps them in a constant battle of catch up. Stay consistent with your current notes schedule and make additional time in the short-term for writing the overdue notes. Start with the oldest notes and just move forward until they’re all done. Once you catch up, you’ll be glad you stayed up on your current notes and you can get right back to your regular schedule!
4. Get support. If you’re having difficulty figuring out which schedule works for you or find that writing notes seems to take you longer than your colleagues, seek out help from your supervisor. Tell them your struggles early on so you have someone to keep you accountable as you problem-solve. Also, talk with colleagues to find out what strategies work for them. It’s great to stay connected with others so you know your struggles are normal and you can also find others who have worked through them. If you’re not a part of the MFTGuide Facebook group, click here to join and connect with likeminded therapists who are making the transition from student to working professional.
Follow these tips and you should be successful in completing your documentation on time! I know it’s not the most exciting part of what you do, but it’s just as necessary as being present during sessions. If I’ve learned anything from reviewing hundreds of client charts it’s that timeliness has a significant impact on the quality of documentation. I can tell when a therapist wrote an assessment or progress note within 24 hours and I can definitely tell when they waited 24 days!
As therapists, we deal with such ambiguous but powerful feelings and ideas. Much of what we do is intangible and it’s sometimes difficult to put into words. Combine that with the stress of studying for exams, dealing with client crises, and lapses in memory over time and you have a recipe for disaster when you procrastinate writing notes.
If you’re looking for more tips on time management and making documentation more relatable to your clinical work, check out my free online training: The Private Practice Paperwork Crash Course. Regardless of what stage you are in your career, there are helpful tips that apply to therapists working in all settings. Now, use the strategies above and map out your plan to get your paperwork done in no time!
Dr. Maelisa Hall is an expert in clinical documentation who loves teaching therapists how to create rock solid documentation so they can spend more time focusing on their clients and less time worrying about paperwork. Click here for instant access to her Private Practice Paperwork Crash Course for mental health professionals.