License Mental Health Counseling

Topic #3: Clinical Documentation

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I have various documentation responsibilities at my site, The Center for Community

Counseling (CCC). Documenting is completed in a computerized password protected

system that CCC uses for intakes, biopsychosocials (BPS), group and individual session

notes, progress notes, treatment plans, and assessment scoring. All intakes, group session,

individual session and progress notes must be completed by the end of each day.

Biopsychosocials must be completed within a day of the end of the clients last BPS meeting.

Treatment plans must be completed by the second individual session and assessments

must be scored the day the assessment is given.

I have written group notes from shadowing a counselor at my site and co-leading

groups. I have had input on writing BPS’s from shadowing a counselor administering

BPS’s. I have written an intake from shadowing a counselor as well as completing intakes

independently. I have not written an individual session note, progress note, treatment plan

or assessment yet. For those I have not written I have received training on them and

reviewed samples or actual client files from my site. The shortest records to document are

the individual and group session notes as there is a specific format called SOAP to be used.

The longest record to document is the BPS because there is so much information that is

required to be included.

There are a few easy aspects of documentation at CCC for me. First, being

computerized is easy for me instead of handwritten. Editing in the computer system is

more efficient for me than thinking through the flow of what to write before writing it out.

Second, the intake forms are brief and basic as they are completed by asking the client

questions. I find that asking the intake questions are an opportunity to build rapport, such

Topic #3: Clinical Documentation

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as using open posture, and using prompting to demonstrate interest, such as saying, “Tell

me more about that.”

A third easy aspect of documentation is using the SOAP format for the individual

and group session notes. The SOAP format gives me the structure and ensures that the

note contains the required clinical information. My site supervisor gave me a brief one

page reference of definitions of what the S, O, A, & P mean. The reference makes it easier to

know where the different components are to be written in the client’s individual and group

notes.

There are a few difficult aspects of documentation at CCC for me. First, group

session notes must be completed by the end of each day. Sometimes there is so much

information covered in a group that it is difficult to find the right words to describe the

clients process and responses or remember who said what. The group session notes should

be clear and concise yet give my site supervisor a clear description of what was spoken

about during the session and how the clients affect appeared to me. I have found that I

write the note and be satisfied with it but then remember something important the client

said or processed when I am reflecting on the session later in the day.

A second difficult aspect of documentation is with intakes. Sometimes when asking

the questions on the intakes, I find that the person is distracted by my writing or they

appear uncomfortable that I am writing down the answers to the questions. Because of this,

I sometimes stop writing and simply let the individual speak. In doing this I am showing my

full attention although I know I should be writing down what they are saying. Afterwards, I

find it difficult to remember the reasons they said they wanted therapy or what was going

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on because the client covered so much. Taking notes and listening at the same time is

difficult. The deidentified example I have attached on the last page is an intake.

A third difficult aspect of documentation is with the BPS. Spending the time with the

clients and asking the questions is easy. The difficult aspect is that there so much

information that is required to be included. When writing the BPS, if a piece is missing or

does not make sense, I must contact that client and obtain the information.

I noticed with the more intakes and BPS I complete, I am more familiar with their

content. Which has given me the ability to know what information I will need when writing

the report. Also, I am getting better at identifying discrepancies when I am with the client

to address them at the time of the intake or BPS rather than contacting the client

afterwards.

While using the SOAP format for individual and group session notes and having my

site supervisors reference page is helpful, knowing how to word the clinical content is

difficult. One of the authors listed in the course syllabus supplemental materials wrote a

Progress Note Planner book. The examples in the book have helped me further develop my

objective clinical writing. In addition to the book, I am assembling a list of samples from

other individual and group session notes that I have reviewed at my site.

To help me with remembering who said what during group, I began using a sheet of

paper with the group’s topic outline (e.g. session goals/objective, activity directions,

discussion/processing prompts, closing activity, etc.). During group, I use the margins of

the outline to jot down a client initial and one word to serve as a reminder of what they

said. I also use the margins of this outline to jot down single words to describe client affect

I notice during group. Knowing what is expected in the SOAP format and having spent

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some time beginning to assemble a sample list of clinical content has helped me to notice

during group what and how to document it after the group is over.