Writing Progress Notes During Sessions: Why it helps and the big mistake to avoid

In my experience, most therapists do not write progress notes after every client session. And most therapists think they should write notes after every session.

Why is there such a disconnect?

For most people, writing case notes after every session is not a realistic expectation.

However, not having a plan for when to write these case notes causes a ton of stress and creates a recipe for note writing disaster.

Here’s the solution many therapists come up with to solve this problem:

“I’ll jot down some notes to myself so I can remember the details later.”

Sounds like a great idea, right? WRONG.

THE BIG MISTAKE MOST THERAPISTS MAKE

My experience working with hundreds of therapists to help them catch up on notes has shown me one very consistent problem:

They vastly overestimate 1) the quality of those notes during session to trigger memories of what happened and 2) their memory, in general.

For this reason, I recommend changing this habit as one of the first steps to overcoming the cycle of getting behind in progress notes.

Then it’s time to really evaluate what is contributing to the problem so that you can create a plan, not just to catch up on case notes, but to stay caught up on case notes.

LOOK AT WHY YOU FALL BEHIND IN PROGRESS NOTES

A commonly overlooked reason for this problem is that therapists are not planning ahead and are writing down notes during session out of fear.

Fear they will forget what happened in the session.

Fear they will forget to write the progress note.

Fear they won’t write a good note without having information written down when their memory is fresh.

But if you plan ahead and know exactly why you are writing what you’re writing, then we can create a plan for you to catch up and stay caught up on case notes.

Here’s an important question to consider: Are you writing process or progress notes during sessions?

If you are simply writing notes to yourself so you remember a few details, but you plan to write a totally different note later and possibly destroy the handwritten copy you have now, then the handwritten note is a process note.

If you are writing down the beginnings of phrases you will use in your progress note and using this as a “first draft” then you are writing progress notes during the session.

This distinction is important because it will help you understand what writing notes during sessions actually helps you with right now.

And that will help you identify which strategy will best solve the problem.

Whether or not your handwritten case notes that you jot down to yourself end up as process notes or progress notes, if you want to break the cycle of falling behind then I recommend you 1) focus on strategies for time management and 2) create some urgency for yourself so that you are compelled to write your case notes within 24 hours of each session.

What’s the best way to create a sense of urgency so that you are motivated to write your note sooner?

Stop writing notes to yourself in session. Now.

But if that feels too scary, and if you are truly just starting a first draft of your progress note, then there are a few strategies you can use to start the note in session and save yourself time.

WHEN WRITING NOTES DURING SESSIONS IS HELPFUL

Now that you’re (hopefully) convinced to stop jotting down random notes to yourself, let’s look at the ways that writing progress notes during sessions can actually be a great time management tool.

If we use the concept of collaborative documentation, then the note is truly a part of the therapeutic process and it can be a helpful clinical tool to incorporate in each counseling session. Thinking of your progress note this way, you can identify strategies that involve your clients in the process (see below).

However, even if you prefer to use a strategy that does not involve your clients, there are some great options that will not only help you write notes more quickly, they will probably improve the quality of your notes, too!

Strategies to save time and get your progress notes done:

1. Write case notes with your clients at the end of every session.

2. Use dictation to start your case note immediately after the client leaves.

3. Use bullet points to write longer phrases when you start a case note, instead of writing words you think will trigger your memory when you come back to it.

4. Use a checkbox case notes template and add in a few details to personalize each note for every session.

The bottom line is that if you struggle to write progress notes regularly, you must identify a way to make the task easier for you to complete. Using one (or a few) of the strategies above will help, but you have to be committed.

I’ve seen many therapists who were months behind in their progress notes catch up… and stay caught up.

No matter how behind you are, you can catch up. Progress notes don’t have to be a dark cloud over your head for your entire career.

But in order for that to happen you likely need to do something different from what you’re doing now.

So tell us in the comments below as your first step: Which strategy are you going to try?