How to Supervise Clinical Documentation

Although some counselors may feel “okay” about their own documentation, few know how to teach this skills to supervisees. And if you struggled with documentation or feel less confident then this becomes even more of an issue.

In this post I’m laying it all out for you… how to train supervisees, how to correct work when needed and how to integrate this teaching into your supervision so it doesn’t take away from the clinical conversations you need to have. So check out the steps below and see if any (or all!) seem like good things to try out with your supervisees.

Reviewing paperwork

1. Read through the notes as a story, not one by one.

The tendency when reviewing notes is to read them week by week for each client. However, when you read only one session note you miss out on the whole clinical picture. Was there something important that was never followed up on? Does the treatment seem to be following a good flow? Have there been any patterns that emerge over time?

2. Check to see if the reason for treatment is clear.

Can you tell, just from reading the assessment and intake notes, why this client is here for treatment? Are you able to identify a clinical need or goals from the client? These should all be evident in the paperwork but should also match your supervisee’s description when you discuss the case.

3. Make notes about what questions come up as you read.

It’s very easy to get caught up in reading a file and forget key points along the way. Use a simple sheet of paper to jot down comments and notes to yourself. Don’t forget to highlight things that are well-written so you can also give positive feedback!

Training on paperwork

1. Write notes together.

One easy way to train is to simply write the notes in your supervision meeting while talking with the supervisee about the session. This allows you to teach them how to summarize and highlight what are the important points while leaving out “fluff” or extraneous details. Another method to this is to watch a sample therapy session together and write notes on the session individually, then share how your notes are similar or different and see what you each focus on. I’ve experienced great success using this strategy with even seasoned clinicians. If you have a group practice or supervise more than one person, this is a great group technique!

2. Talk about treatment planning and how that looks in real life.

Don’t neglect treatment planning with your supervisees. What I find when I talk with therapists about their treatment plans more often is that they tend to adjust them more often. And that’s okay! Check in to see where treatment is going and if things need to shift. That may mean the treatment needs to shift a little to better meet the client’s needs or it may mean the treatment plan needs to be adjusted.

3. Review one file each meeting.

This will insure the notes are getting done, which is a big piece about documentation! It’s very easy for counselors to fall behind in notes but if you’re regularly reviewing at least one file you’re more likely to see a completed file or to at least catch a problem early. This will also create a habit of reviewing files for both of you.

4. Create an action plan for catching up on notes. Keep them accountable to it.

This is HUGE! As soon as even 1-2 notes are missing, make a plan to catch up and check in. As the supervisor, I do believe it’s your job to follow up and make sure this doesn’t become a bigger problem. Be supportive but also create a firm deadline and provide the needed time to meet that deadline.

5. Have your supervisees attend a training. Even better, attend together!

Shameless plug here, I’ve got a couple trainings on this topic, at different levels of intensity. Check out the Meaningful Documentation Academy to see if investing in even just a 45 minute training may help your team. Part of the reason I do what I do is that not many others are doing it so I don’t have a ton of other resources to give in this area, but seek out your local professional association to see if they’d be willing to sponsor a training on clinical documentation. When these do occur, they’re typically very highly attended.

And if you're reading this is a supervisee, suggest some of these with your supervisor! Many supervisors are nervous about documentation as well but if you start the conversation, they are likely to help you out.

Now tell us… what strategies did your supervisor use that helped you with documentation? Any lessons learned that you can share? I’d love to hear in the comments below!