Question: “I don’t know if I’m writing relevant or even useful case notes”
When it comes to writing case notes, I sometimes wonder if everything I’m writing is relevant or if I’m writing too much.
As a new therapist, I’ve received different answers depending on who I’ve asked. Some lecturers and supervisors say that notes should be thorough and detail each session with clients, while others have said a paragraph for each session after the intake session is enough.
During my training, one lecturer insisted we follow a structure which had different sections including the session details, interventions, plan for the next session, and how the client is progressing. Sometimes, it feels excessive and I struggle to know what to write if two or more sessions are similar.
Of all the training we get and all the discussion on being a good therapist, I feel like we don’t learn a lot about how to keep good notes. Can you please share your thoughts on how to write good case notes?
Response from Dr. Chua:
Thank you for sharing your question, it’s definitely a common concern among new therapists how they can keep good case notes and, as you mentioned, different professionals will have their preferences and styles.
The good news is, like any skill you practice, writing notes of your work with clients will improve with time and it’s great that you’re conscientious about maintaining good records and recognising the importance of doing so.
Training programs should cover how to write quality case notes, as these technically could be called on and included in any legal situations that require the therapist to provide them to the court. They’re also important in terms of helping you keep track of your work with clients, and for any other relevant parties who might review them with the client’s consent (e.g. referrals).
That said, it is helpful to have in-depth knowledge about how to maintain quality case notes and this can be glossed over in favour of other elements of clinical practice deemed more important. In fact, your notes play a vital role in ensuring effective and ethical practice.
It’s necessary to make a distinction between the types of notes therapists typically keep in their work with clients. We can compare psychotherapy notes with case (or progress) notes:
Case (or progress notes) record information including client care, treatment plans, medical history, and other important information. They should be objective, clear, and concise. Common formats of case notes are DART and SOAP, which provide a solid guide for maintaining clear records. These notes might be shared with other health professionals involved in treatment, or other therapists if the client is referred elsewhere.
In a nutshell, these notes cover: what was talked about in session; client response/behaviour; interventions used; and action plan for subsequent sessions. If notes are to be shared with anyone, clients must give their recorded consent (e.g., as part of a signed informed consent for therapy; a written statement giving their consent for a valid reason). Clients also have the right to see these notes within a reasonable time upon request.
If you feel like your case notes are similar, it could be that what you’re doing in session isn’t working as well as you’d hoped, or it could mean that you’re still exploring the client’s issues and conceptualising the case. If you feel like it’s the former, you can always check in with your client during session to see how they are feeling about your work together:
“I’d like to check in with you to see how our work together is going. Is there anything you feel we could be doing more of or is missing in session? How are you experiencing our time together?”
This can be helpful in emphasising your client’s part in the collaborative nature of therapy, and it provides useful feedback in real-time. Just to be clear though, checking with your client about progress should be done regularly regardless of how your case notes are,
Psychotherapy notes (sometimes called process notes) are the therapist’s private notes that reflect their observations, hypotheses, questions for your supervisor, and any thoughts or feelings relating to the session. Clients don’t have a right to see these notes and they would be kept separate from case notes. They would also not include medical details or records, any test results, or summaries of diagnosis or treatment plans.
Since psychotherapy notes are, in effect, the therapist’s personal notes intended for their development, they are not required to be shared except for some rare occasions such as relating to legal requirements (you can check this with your licensing or regulatory bodies).
In short, case notes should be objective, clear and concise (recording minimum information); and psychotherapy notes are for your own reflection and development and should be kept separate from case notes. While you’re not required to keep psychotherapy notes, it can be helpful to keep them as a way to reflect on your work over time and consider the challenges you face, for example, with specific cases, demographics, or issues (BPD, GAD, MDD, and so on).
One book I would recommend is The Adult Psychotherapy Progress Notes Planner by Arthur E. Jongsma, if you would like to read more about maintaining quality notes. Don’t worry so much if your case notes are similar over the course of one or two sessions – sessions typically aren’t filled with ‘Eureka!’ moments or leaps in progress. Take your time with clients and trust the process, but do keep in mind to reflect on your work and check in with the client if you feel like your work together has become stuck or stagnant.
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