Progress Notes [PDF]

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HIPAA guidelines about electronic data storage,communica-

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gtotJp-carefacilities where many different treatmentprofessionalsinteract with many different patientsand needto have readyaccessto key informationquickly.Without a standardformat,it is nearlyimpossiblefor differentmembersof a treatment teamto frnd information in a record. Standardizednotes also ensurethat eachmemberof the teamis working consistentlyon an identifiedproblemor goal for the given patientandthat each treatmentteam memberfollows a structuredprocedurein observing the patient's status,recording information about that status,assessingthe patient's condition, and basing treatment on the assessment. It is very likely that your internship placementwill have guidelinesfor keepingrecordsand recordingprogressnotes.If your agencyhas suchguidelines,you must learnthem,practice using them, and get feedbackto be sure you a"rewriting your notescorrectly.As noted earlier, most agenciesconductperiodic auditsto ensurethat record keepingmeetsagencyguidelines.By making sureyour recordsandprogressnotesareup to standards,you can saveyourself and your supervisorproblems later.As a check, interns should initiate their own record and progressnote review with their supervisors.Supervisorstend to get busy andoverlooksuchdetails,so it is a sign ofresponsibility ifinterns take the initiative to be surethey are keeping notes. acceptable In your clinical work you are likely to encountertwo types of ongoing notes regarding treatment.For convenience,and consistencywith laws suchas HIPAA, we will refer to theseas progressnotes and psychotherapynotes.The former describe recordsthat are part of the documentationof patienttreatment availableto otherstaff.By comparison,psychotherapynotesare your personalrecordsof the eventsof specifictherapysessions or relatedinteractions.Understandingthe differencesbetween thesenote types,and learninghow to use eacheffectively,wiil help you becomemore effrcientandeffectivein both your treatmentandyour recordkeeping.

PROGRESS NOTES Progressnotesare the core of most clinical records.They provide a record of events,are a meansof communicationamong professionals,encourageus to review and assesstreatmentissues,aliow other professionalsto review the processof treatment, and are alegal record.Progressnoteshave also seenincreasing use by insurance providers seeking to determine whether a treatmentis within the realm of servicesfor which they provide compensation(Kagle, 1993). In writing progress notes,you must keep all thesefunctionsin mind. When I write progressnotes,I find it helpful to ask myself severalquestions.First, asI write, I review the eventsin orderto again assessand better understandwhat happened.This helps me processandcheckmy treatment.Next, I askmyself: If I read the notes severalmonthsor yearsfrom now, will they help me rememberwhat happened,what was done,and why?

BecauseI may not be the only one to read my notes,I considerwhat would take place if somethinghappenedto me and anotherclinician picked up my clients. Would my notes enablehim or her to understandthe client and treatment?If I am in a setting where other professionalsrefer to the same record,I ask whetherthe notesI write will adequatelyand accuratelycommunicateto them. I include legibility in this consideration.If my handwriting is so poor that others cannot readit, the noteswill not do them or the client much good. Finally, and very importantly, I ask,What would be the implications and impactif thesenoteswereusedas a legaldocument in a court of law? Tvprsor PnocnrssNores The two most commontypesof progressnotesareproblem-orientedand goal-orientednotes.As the namessuggest,problemorientednotesrefer to one or more specificproblemareasbeing addressedin treatment(Cameron& Turtle-song,2001;Weed, 1971),whereasgoal-orientednotesfocuson specifiedtreatment goals,with eachentryrelatingin someway to a goal.In systems that use problem-or goal-orientednotes,eachtherapist,or the treatmentteam as a group,identifiesseveralkey areasoffocus in the client's treatment.For example,problemsmight be identified as: l. Initiatesfights with otherresidents 2. Doesnot participatein socialinteractions Expressed asgoalsthesemightbe stated: 1. Reduceincidenceofinstigatingfights 2. Increasesocialization Once a list of the problems or goals is established,progress notesthenrefer to them by numbeJor name. The theorybehind this approachis that it helpsstafftarget their intervention to meet specific treatmentneedsor goals. Suchnotesmay alsohelp demonstrateto insurersthat the treatmentprovidedis systematicand is relatedto specificproblems or goalsfor which compensationis being provided. Norrs SrYteor PRocRess In mostprogressnotes,writing style is not important;clarity, precision,andbrevity are.Your goal is to recordall the essential informationin aslittle spaceandtime aspossible.Because you may be writing and reading notes on many patientseach day,you will want to saveiime by includingonly the essential details.By keepingyour notessuccinct,you will alsosavethe time of otherswho may readthem. This is especiallyimportant in settingswhere notes are sharedamong many professionals,eachof whom has contactwith many patients.When a clinicianmust readmany notes,everyminute savedin reading and writing addsup. As long as the notesare kept accuratelyand all essentialinformationis provided,the time saved

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in charting can be better spent in direct clinical contact or other activities. Using shorlhandis one way to shorlenprogressnotes.If you are taking notesprimarily for your own use,any systemof shorthandwill do as long asyou can decipherit later.However, if you are writing notesin a recordthat othersshare,it is essential that any shorthandbe understoodby everyoneand accepted by your institution.If thereis a possibility of misinterpretation, you are betteroff writing things out in full. You shouldalso be aware that different settingsmay have different standardsfor using shorthandor abbreviations,and somemay not allow any shorthandat all. If you take notesas part of your internshipresponsibilities,checkto be surebeforeyou write.

the information of when, where, and who can be conveyedin a "When' refersto the dateandtime the eventocsingiesentence. curred. Some people prefer to put date and time at the end of a note,but I suggestyou startthe notewith this informationfor ease of referencelater. "Where" indicatesthe location of the event.If the location is alwaysthe same,suchas a clinic office, this canbe omitted. However,if many locationsare possible,as in a school, hospital,or othei large setting,it helps to note the exactiocation. Next you shouldindicate "who" played a significantrole in or observedthe eventyou arenoting. Noting who waspresentcancome in handylater ifthere is a needto get additionalinformation about a specificeventor client. Onceyou haveprovidedthe basicinformation,you should describe"what" is promptingyou to write the note.This may be somethingroutine,such as "Mrs. Smith has shownLittlechange REDNOTEFORMATS STRUCTU duringthe pastweek. She continuesto pacethe hall and talk to herself."The informationmaybe a significantchangein a client's Dnnr Nores appearanceor behavior: "During individual therapy today, informedme that he hasbeenvery depressed Joseph andis thinkSomeof the most widely usedformatsfor treatmentnoteshave ing killing of himself." The more significant the event, the more significantproblems,especiallywhen appliedto psychological, progress space will be dedicated to the corresponding note. One as opposedto medical,settings.One exampleis the SOAPformat, which is part of the Problem Oriented Medical Records would certainlywant to expandon the secondnotation. (POMR) system(Cameron& Turtle-song,2002; Weed,1971). The SOAP format wili be discussedshortly,but first let me offer Assrssnrnr an alternativethat most internsfind very helpful asthey learnto Having describedwhat you observed,the next step is to recordyour assessment of what it means.This is the "why" of keeptreatmentnotes. the event. You do not always have to offer profound insights This systemactually evolved out of somejoking around nor do you alwayshaveto know what someaboutmy frustrationwith the SOAPformat, which was at the time or explanations, required of all notes for my internship placement.The acronym thing means.Sometimesthe most importantnotesare about for my altemativesystemis DART, but it beganas DIRI, which behaviorsthat stand out preciselybecausetheir meaningis shows the humor behind its origin and explains why it would not exactly clear. For example, if a client who is normally probablyneverbe adoptedin hospitals.Humor aside,the letters rather quiet becomesvery talkative and energetic,the meanrepresentusefulconceptsthatwill help guidemostprogressnotes. ing of the changemight not be clear,but one could note it, or ask othersto offer ffyour agencydoesnot require adherenceto someother standard, suggestsome possibleconsiderations, their insights. the DARI format is a good methodto follow. To help guide your assessment,think about how the The DART system is most useful when you are writing notes about a specific client or event.The D in DART stands presentevent or behaviorrelatesto other knowledgeyou have for a descriptionof the client andsituation.A is for assessment about the client and treatment.How doesthe presentsituation of the situation. (This A was originally 1, which stood for the relate to previousbehaviors,to recent events,to the treatment clinician'simpressionandproducedthe initial acronym.)R is plan, to other factors? Rememberthat most eventsreflect a for the responseof the clinician and client, and 7 is for treat- combinationof both lasting andtemporaryfactorswithin theinmentimplicationsandplan. Oneway to think of this systemis dividual and within the environment.Thus,you might observea that when you write progressnotes you must tell what hap- changein a client's behavior and note that it seemsto reflect pened,what you madeofit, how you responded,andwhat you stressesover recentfamily conflicts and may alsobe a reaction plan to do, or think should be done, in the future. This se- to the overall level of tensionin the treatmentfacility. The most quenceof eventsis not only a useful way to conceptualize importanttaskis to give somethoughtto whatyou observedand progressnotes,it is also a useful way to approacha treatment try to relate it to your overall knowledgeand treatmentof the client.Again, this is notjust good notetaking, it is soundcliniinteraction. cal practice. Descntprtorrt The fust part of any progressnote shoulddescribethe basic W Resporusr questionsofjournalism:when,where,who, andwhat.In practice, In good clinical work you must first take in what is happening thesewords are not actuallyusedin the progressnotes,but the and what the client is doing and saying.Then you must assess notesmust containthe informationthe words subsume.Usuallv. what this means.Your next task is to respondin someway.Your

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il nruoCnsrNoTEs 133 Rrconos, WRmTG,TREATMENT Cururcnl this sequence.After describing Drogressnotes should reflect you did in response.The andassessinga situation,recordwhat descriptionof your responseneednot be lengthy'but it must accuratelynote any importantdetails. Like your clinical response,your record should reflect a well-foundedand rational treatmentapproach.Hereit is somejudge your timeshelpful to considerhow other cliniciansmight It may alsobe usefulto think aboutthe legalimplicaresponse. dons.As a legal standard,if somethingis not recorded,it is diffrcultto prove it was done.Learn to recordscrupulouslyanything you do or do not do that might laterbe consideredimportant. Be conscientiousabout noting suchthings as referring a clientto someoneelse,administeringformal testsor other measures,if giving homework assignmentsor developing contracts,and schedulingfuture contacts.Also keepnotesif you consultwith someoneabouta case.Includeboth the fact that you consultedand a summaryof the consultationand results (Hanis,1995). To the extentthat the severityof a client's concernsor the riskinessof a clinical decision increases,records should be moredetailed.Bennettet al. (1990)suggestthatrecordsshould describethe goal of the chosenintervention,risks andbenehts, and the reasonfor choosinga specific treatment.It is also advisableto indicate any known risks, availablealternativesand why they were not chosen,and the stepsthat were taken to maximize the effectivenessof chosentreatments.In some instances,documentingwhat you did not do and why you decidednot to do it can be just asimportantas documentingwhat you did do. As further information, it is often usefulto note any information provided to, or discussedwith, the client, and the client'sresponse. In essence,this process is tantamountto "thinking out loud" in the record. Gutheil advised: 'As a generalrule, the more uncertainty the more one should think out loud in the record" ( 1980,p. 482).Inthis process,the clinician is recording not only the actiontakenbut the reasonsfor taking or not taking an action. If questionsarise later, the explanationis already documented.In a legal context,Gutheil stressedthat for liability reasonsthis processis importantbecauseit reducesthe possibility of a ruling of clinical negligence.

If you areworking in an agencywherea daily log is maintained,it is oftenpossibleto leavenotestherefor otherstaff'For example,you might conclude a note by suggestingthat the eveningstaff keepclosewatch on a patient.If somethingis really impofiant,be sureto highlight it in someway in your notes' Use stars,bold writing, or othermethodsto makethe notestand out. If the matteris urgentor life-threatening,do not leavethe matter to progressnotes alone; speakdirectly to someoneresponsible theconversation. anddocument DART ttt PRncrrcE To demonstratehow the DART notation approachmight work in practice,supposeyou were working in a schoolsettingand a child camein with severestraplikebruisesand welts acrosshis back.You suspectthe child may havebeenabused,so you discussit with him. He seemsto avoid answeringbut finally says he fell andhurt himself. The following sample notes illustrate how you might recordthis using the DART format. In this example,the DART initials are usedto help organizethe note and for easeof later locationof information.As you readthe example,identify how andwhat informationis includedin eachof the main areas.You may find someinformationfollowing oneinitial that might also go with a different initial. In contrast to other systems,the DART model is not so concernedwith what goeswherein the notes.What mattersmost is that all the importantinformation setsrecordedaccuratelvandin a usefulmanner. Monday: After recessat 10 a.u. today,TimoD : 1011812004 thy North was taking his jacket off and in the processhis shirt pulled up revealing straplike red welts acrosshis back.At noon breakI spokewith him while the otherchildren were out. I said I noticed he had somered marks on his back. He looked away and shruggedwithout answering. I askedwhere he got them.,and he said he did not know.Thenhe saidhe hadfallen down overthe weekend.I askedif his parentsknew,andhe saidyes.That afternoonI met with the school nurse, Karen Jones,and Tim. The nurselookedat the marksandaskedTim similar questions; he againsaidhe had fallen.

Pmru Tnenrmerur Following the descriptionof your immediateresponse,the final element of a well-written progressnote is your plan for future treatment. This may be as simple as a note saying "schedulefor next Monday" or "Continueto monitor condition daily," or it might be more complex, as in "Next session we will explore family issues. Client will bring written deR: scription of eachfamily member,and we will completefamily diagrams."Notes of this sort allow you to refer back to refresh your memoryof what was planned.This might seemunnecessaryto you now,but if you havelargeand complexcaseloads, suchrecordswili help you keep track of your clients and their treatment.

The marks do not look like they came from a fall. Karen Jones,schoolnurse,agrees.We areconcernedaboutpossible abuse.This child hascomein with questionablebruises before,but none were this severe,and he has always offered plausible explanations.Given the nature of the presentmarks,we believethe situationwaffantsnotification of Child ProtectiveServices. I notified the schoolcounselor,Alice Black, and we contacted Child Protective Services.The contact person at CPS is William Randolph,MSW. He askedif we thought therewas imminentdangerof severeharmto the child. We replied that we did not have enoughinformation to know that. He suggestedrn'eschedulea meetingfor Wednesday,

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CHnprpn6 October 20, at 4 p.v. If further concerns arise before then, we will call and inform him.

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We will keep watch on Tim and check for furlher signs of injury. Future action wili be deternined at Wednesday meeting. Signed, Joyce Jefferson, MSW, Date, 1011812004 cc: Karen Jones, Alice Black, William Randolph

doubt be very familiar with it and can give you usefulsuggestions for putting your progressnotes in the properformat for that institution. If you are interestedin knowing more about SOAP,seethe originalwork by Weed(1971)or the moregeneral review of medical recordsby Avery and Imdieke (1984). Most settingsthat use SOAP or any of the other standardnote formatswill havetraining materialor workshopsthat canteach you more aboutwriting thesenotes. ExrRctse

SOAPNOTES

If you arenot alreadywriting ciinical notes,you may wantto developyour skillsby choosinga recentinteractionwith a friend or earlier, noted one of the As more common standardizednote- client anddocumentit asif you werewriting a progressnotein a taking methodsis the SOAP format. So-calledSOAP notesare ciinical record.Ifpossible, review the note with your supervisor actually part of a broadersystemknown as Problem Oriented andrequestfeedbackabouthow you couldimprovethenote. Medical Records.Comparableto the structurerecommendedby Piazza and Baruth (1990), which was discussedearlier in this chapter,the POMR system includes four components,com- TIME-SEQUENCED NOTES monly referredto as the clinical assessment, problemlist, treatmentplan,andprogressnotes(Shaw,1997).SOAPnotesfall in As notedearlierin this chapterand in the discussionof HIpAA and ethicsin Chapter3, psychotherapynotesare differentthan the progressnote portion of this system. progress notesand should not be kept in the patient'sgeneral The lettersin SOAPstandfor subjective, objective,assessment, and p1an."Subjective" refers to information about the record.In contrastto the DART and SOAP approaches, which client'spresentsituationfrom the client's subjectiveposition. are usedprimarily to record specificeventsor interactionsand One way to think of this is as the client's presentingcomplaint are kept in the generalrecord, a therapist'spersonalcasenotes or descriptionof how he or she is doing and what he or she from individual sessionstypically follow a differentformat and needsor desires."Objective" informationis meantto be the ex- servea different purpose.Time-sequenced notes are the most ternal data that are being observed.In a medical setting,this common form of notation for therapy sessions.In time-semight be blood pressure,temperature,and the like. Suchobjec- quencednotes,the therapysessionis describedasit progressed, tive dataare often much lessclearin psychotherapyinteractions with individual elementsdescribedsequentiallyin the order in than in medical practice,though it is possibleto offer descrip- which they occurredin the session.Sometherapistsmakethese tions of, for example,the client's affect,appearance, and man- notesduring the therapysession.Otherswait until the end of a nerisms.The "assessment" portion of a note reflectshow the sessionto recordwhathappened. therapistintegratesand evaluatesthe meaning of the client's The sequentialapproachis oftenusedfor recordsoftherapy subjectivereport andthe objectiveextemallyobservabledatain sessionsbecausetherearesimply too many elementsto address light of all the other information known aboutthe client. From eachseparatelyfollowing a more structuredformat. Sequential this assessment, the plan of treatmentaction is then recorded. notesalso enablethe clinician to observethe order of eventsas Although the conceptsbehind Problem-OrientedMedical they occur within a session.This can provide extremelyuseful Records,from which SOAP developed,are quite valuable,my clinical information.For example,it is probablynot merecoinexperiencewith the SOAPformat suggeststhat the terminology cidenceif a client beginsby describingfamily conflicts,then is rather ambiguousfor use outsidemedical settings,and en- shifts the topic to problems at work. Sequentialnotesfollow forcementof the terminology can be paradoxicallyrigid. This this shift and enablethe clinician to noticeit in the recordeven situationcan readily lead to needlessdebateabout whetheran thoughit might havegoneunnoticedduring the session.An exentry should have been placed in the S, O, or A section ample of an abbreviatedsequentiallyordered progressnote (Cameron& Turtle-song,2002).I havealsofoundthateffortsto from a therapy sessionfollows. Note the use of an informal conform to rigid SOAP guidetinestend to produce contorted shorthandto savetime: writing that may obscureratherthanciarify what happenedand 2/9/20042-3p.trt.JA begansession by revuof 1stwkssesn.Said what wasdoneaboutit. Nevertheless, manyinstitutionsusethe he had thought about it & did not understnd whyhehadcriedabout POMR and SOAP system,so you shouldbe familiar with them father.Weexplored this more. JA cried again, rembrdhshingtrip and develop strategiesfor following these formats. Cameron andfathrtaknghis fish away.FeIthumiliated. Realized thiswas and Turtle-song (2002'1offered some very useful suggestions typicalpattem.Gaverecentexample of visitduringXmas.Hisfafor how the SOAPformatcanbe usedin mentalhealrhsettings. ther was critlcal of JAs job, an argument developed and JA reIf this systemis usedin your placement, your supervisor will no turned home early. We explored pattern of seeking approvai and

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Rrconos, Rt"to CnseNores 135 WnmNG,TREATMENT Cururcnl fearingrejection.JA realizedthatangeris alsothere.Thiscomes what you chooseto put in your notesis up to you and your suaswe1l.JAis oftenangryw wifeif shedisapproves pervisor,but keepin mind the benefitsaswell asthe risks,and, outin marriage whenhecooks again,be awarethat your notesmay be read by other persons. two examples, of anythinghe does.He described butis with ownbehavior andin childcare.Heis notcomfortable Agreedto explorethismorenxt sessn. havinghardtimechnging. In a one-hoursession,there would obviouslybe more that could be recorded,but in this examplethe therapisthas chosen to note the eventsand topics she consideredmost important. This will vary from therapistto therapistandis alsocloselytied to theoreticalorientation.Analytically trainedtherapists,for example,would be likely to make much differentnotesthanthose recordedby a behavioraltherapist.

SIGNING NOTES

The frnal stepin writing progressnotesis signingthem.As anintern, you shouldcheckwith your supervisorto be sureyou understandexactlyhow notesor otherdocumentsareto be signed and how you areto identify yourselfwith your signature.Some institutionsrequireinternsto sign notesand identify themselves as"PsychologyIntem" or "social Work Student."It may alsobe necessary for your supervisorto co-signanywork thatyou write. This might includedaily progressnotes,or it might apply only to NOTES OR PROGRESS PROCESS more lengthyreports.Becausedifferentagenciesor institutions will havedifferentpolicies,the only sureway to know you are Processnotes are yet another type of note with which you following proceduresis to askfrom the beginning. should be familiar. Processnotes refer to notes in which the Along with being sureto list your statuscorrectly,you should therapistincludespersonalreflectionson not only the observ- alsoconsiderthelegibility of your signature.Mine happensto be able interactions in treatment but also the therapist's own almosttotally illegible. With experience,secretaries,students,and thoughtsand considerationsof suchthings as the unconscious colleaguesall learn more or lesshow to deciphermy scratchings, dynamicsof a patientor the transferenceor countertransference but thosewho haveless experienceand do not know me well are issuesin therapy. As contrastedwith progressnotes, which often at a loss.This canpresenta problemfor progressnotes,befocus more on the extemally observable,empirical eventsof causesometimestherearequestionsrelatingto notes,andpeople treatment,processnotesdelve into the psycheof the therapist needto know who wrote them. ff no oneknows who you areand andpatient.Notes ofthis type can be especiallyuseful in train- they cannotreadyour signature,it is going to be difficult to find ing becausethey allow interns and their supervisorsto review you. My solutionis to alwaysprint my nameabovemy signature. not only what was going on externallyduring the interactionbut Becausemost peoplewill be less familiar with internsthan with what the intern was thinking (Fox & Gutheil, 2000). Profes- regular staff, it is especiallyimpoftant for you to be surepeople sionalstrainedfrom a psychodynamicperspectivewill be quite can readyour writing and to identify your statusclearly. familiar with processnotesand may considerthem essentialto training and treatment. Prior to the establishmentof the protectionsnow included DICTATION in HIPAA, manyprofessionalswho valuedprocessnoteshadlegitimateconcernsthat suchnotesmight be soughtby insurance Whetheryou write or dictateyour progressnotes,their content companies.Legally, clients also have accessto their general and structureshould follow the guideLinesoffered thus far. This medical records, and a client who reads a therapist'sprivate may soundeasy,but for mostpeople,dictationtakessomegetting latent desires, usedto. The typical approachof beginnersis to write their notes speculationson the client's libidinal attachments, the first, thenreadthem onto the recorder.That is not exactly a model understand not or other potentially sensitivemattersmight of efficiency.If you work in a settingwheredictatednotesarean These coninvolved. purposeof suchnotesor the terminology option or requirement,the following suggestionsmay help. protections, but, cernshave largely been addressedby HIPAA Dictation is like writing; both take practice to develop. from again, only if psychotherapynotes are kept separately peoplebegin dictating,it may help to work from a brief When however, be otherrecords.HIPAA protectionsnotwithstanding, outline. This is not as lengthy or redundantas writing written proawarethat processnotesmay also be problematicin legal entry beforehand,but il doesprovide somestructure entire the proceedingsand, as discussedin Chapter3, HIPAA doesnot point. It is alsopossibleto usea generaloutline, reference a and (Harris, 1995). tect notesagainstcourt orders DART format, and then make notesaboutthe spethe as such to Given theseconcerns,many professionalshave chosen each client or event. for details cific reducesubstantiallyor eliminatethe introspectiveand theoretiyou keepin mind that the peoplewho are dictating, When cal contemplationthat was once standardin processnotes.This your record have only what they hearon tapeas transcribe will is unfortunate,becauseprocessnotescanbe tremendouslyvaluRememberto speakclearly, they will write. for what basis a able in clinical practiceand especiallyin clinical training. For and verbally indicate names or terms, unfamiliar out spell an excellentreview of this topic and suggestionsfor effective punctuation, paragraph or symbolsgo. With the breaks, where use of processnotes, seeFox and Gutheil (2000). Ultimately,

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advent of digital recording systems,one can now speakquite rapidly, becausethe persontranscribingthe notecan easilystop or move backor forward to keepup. If a slower,tape-basedsystem is in use,you may needto speakmore slowly so the typist can keep up. Whateversystemyou use,you can savethe typist time by usingthe pausebuttonon the recorderwhen you stopto think. Also, do not be afraid to make correctionsif you realize that you madea mistakeor left out a detail earlierin your report. Ratherthanrewindingandstartingover,if you realizeyou made . an error or omission,you can say somethinglike, "I just realized I left out a sentence.Could you go backtojust after . . . and insert.. . ." Whenyou havedictatedthe correction,you cancontinue from whereyou left off. In most large institutions, you may never meet the staff who transcribeyour dictatednotes.Becausei find this structure unfriendly,I make it a point to get to know the peoplewho will be typing my notes.Building relationshipswith records,secretarial, and other staff is not only rewardinginterpersonally,it can also help prevent and more easily resolve a host of problems. Good secretarialwork can be extremelyvaluable,so it is importantto respectand supportthepeopleyou work with. One way to showyour respectandbuild a relationshipis to visit with folks when you begin your internshipand stopby from time to time later to sayhello. It alsohelpsto concludeyour recordsby thankingthe personwho is doing the typing andacknowledging that person'swork. Future directions for dictation involve voice recognition systems,in which one speaksdirectly to a computerthat then prints the text of what is said.Thesesystemsaregrowing in sophisticationandcan alreadymanagecomplexclinical terminology and editing functions. However,such systemsrequire the userto speakclearly and relatively consistently.This may take somegetting usedto, but with practiceone can learn to interact effectively with such systems. Exenctsr To gain practicein dictation, think of an interactionthat occurredin classor with your peers.Usea tape-recorder anddictate your notes as ifthey were to be given to a secretaryfor typing. Then,either type the notesyourselffrom the tape,or aska willing friend to try to type from your notes.Your friend can offer feedbackabouthow fast you spoke,whetheryou misspelleda technicalterm, whether you were clear aboutpunctuation,and so on. Remember,dictation is a skill that takestime to learn.Do not be embarrassed abouthearingyour own voice or abouthow your notesreadon the first try. With practice,you will find that dictatednotesgo much faster and can be iust as informative as rvrittennotes.

PROGRESS NOTESAND SUPERVISION I have describedthe importanceof progressnotesfor meeting agencystandards,ethical guidelines,and legal documentation.

In addition,progressnotescan also provideusefulmaterialfor clinical supervision.The general subject of supervisionwas discussedin Chapter4, but a few additionalcommentsarewar_ rantedin the contextof notes. It is a good practicefor internsand supervisorsto makere_ views of progress notes a regular part of the supervision process.This review servesseveralfunctions.As notedearlier, reviewing notes with supervisorshelps to ensurethat the in_ tern'srecordsareup to agencystandards.Becauserecordkeeping is animportantbut often overlookedpart ofclinical training, supervisorsmay wish to offer advice about the contentor the style of an intern's notes.Reviewingnotes also allows interns the opportunity to ask about any issuespertaining to record keeping and note taking. Beyond the clerical aspectsof note taking, reviewing notesand recordshelps supervisorsobserve what interns considerto be significantabout a caseor therapy session.Supervisorscanmonitorthe intern'srecordsofthe con_ tent and processof therapy sessions,and the notes can be re_ ferred to as neededto supplementor guide casediscussions.

USINGYOURNOTES Having devotedthis chapterprimarily to how to keep records and progressnotes,it shouldnot be forgottenthat the primary pu{poseof notesis to assistthe treatmentof your clients.It is surprisinghow often therapiststakenotesat the end of sessions but then do not refer to them againbeforethe next sessionwith their clients. This can easily happen as therapistswith busy schedulesshift from seeingoneclient to the nextwith little time in between.Understandablethough this may be, the quality of treatmentmay be lessenedas a result. I confessto havingbeenguilty of this myself on occasion. I recall an instancein which a client said he had given a great deal of thoughtto what was saidlast week, and I found myself intemally strugglingto recalljust what it was we haddiscussed. It has also happenedthat I "assignedhomework" (i.e., suggestedthat a client do or write somethingbetweensessions), which I then forgot to discuss.Clients have called me on this and in some caseshave expressedtheir displeasureover what appearsto be a lack of concemor attention. Beyond a matter of courtesy or simple forgetfulness, many clientsmay actuallyconsidersuchoversightsunethical. In a surveyof 96 adults, someof whom had experienceas clients and others of whom had not, Claiborn, Berberoglu, Nerison, and Somberg(1994) found that in a list of statementsabout60 possiblehypotheticaleventsthat might occur in therapy,the statement"Your therapist does not remember what you talked about in the previous session',was ranked fourth highest among eventsconsideredto be ethically inappropriate.The mean ranking for this item on a scaleof 1 to 5, with 1 being"completelyinappropriate,"was 1.32.Clearly,at least in this sample,recipientsof clinical servicesplaceda high value on therapistsbeing aware of the content of previoussessions.

Rrconos, nno CnsrNorrs 137 WnnNG,TREATMENT Cr-rrurcnr Facedwith the many demandsof ciinical work, it is all too easyto becomecareless,or to let other taskstake precedence overnote taking (Kagle,1993).If you need10 minutesfor note taking betweentherapy sessions,schedulethat in and do not aliow it to be takenup insteadwith phonecalls or other distractions.Unlessthey areurgent,savethoseothermattersuntil you havefinished your notes.You will be surprisedhow much gets forgottenor lost evenby the endof the day.The longeryou wait to record your notes,the less accurateand less valuablethey will be. When it comesto clinical reiord keeping,a littie compulsivity is not a bad quality to develop.Not only will well-kept G U I DE L IN E S notesenhanceyour clinicai treatment,they can also make the OTHER differencebetweenwhetheror not an insurancecompanypays This book hasemphasizedrepeatedlythat you must know your for services.In our litigious society well-kept progressnotes limits and be opento learning.This appliesto recordsand notes may also saveyou untold legal problemsif you are evercalled as much as any other aspectof your internship.If you do not on to producethem in court. knowhow to write a note,or if you areunsureof the wording to use,ask for heip. If you are describingan interactionwith a client, do not write notes designedto impress everyonewith REFERENCES your skills. While you are an intem, humility is a virtue, and hubriscan get you into trouble. Remembersimplicity and ob- Alter, C., & Adkins, C. (2001). Improving the writing skills of social jectivity. work students.Journal of Social Work Education,37, 493-505. Another principle of note taking is to be constructive.This Alter, C., & Adkins, C. (2006).Assessingstudentwriting prohciencyin graduateschoolsof social work. Journal of Social Work Educais especiallyimportant if you are writing notesin a recordthat tion, 42,337*354. to others.Althoughpart of your task is to assess is accessible AmericanPsychologicalAssociation:Committeeon ProfessionalStanandtry to understand what you observe,your pulposeis not to dards. (1993). Record keeping guidelines.American Psycholoascritreblame.Your goal is to faciiitate treatment,not to be critgist,48,984-986. ical of clientsor staff.For example,it would not be constructive Avery,M., & Imdieke,B. (1984).Medical recordsin ambulatorycare. to write a note such as "Dennis is up to his old tricks again. Rockville,MD: AspenSystems. Foundhim masturbatingin front of the television.SometimesI Baird, 8., & Anderson,D. (1990).A dual-draftapproachto writing. think we shouldcut the thing off." This may soundshockingly TeachingProfessor 4(3), 5-6. callous,but I read preciselythis note in staff records.Interns Barker,R. L. (2003) TheSocial WorkDictionary (5th ed.)Washington, DC: NationalAssociationof SocialWorkers. learn by example,but some examplesare best not followed. G. R., & Greenwood,A. Imaginethe impact of sucha note if readby an outsideprofes- Bennett,B. E., Bryant, B. K., Vandenbos, (1990).Professionalliability and risk mancLgement Washington, sional,a family member,or in a court of law. DC : AmericanPsychologicalAssociation. For simiiar reasons,if you are working in an institution Bower,A. G. (2005).Thediffusionand valueof heahhcareinformation where many staff membersrecord notes in the same book, technology,RAND (availableonline at http://www.rand.org/pubs/ usingthe recordto questionor attackthe conductof other staff 2-Lpdf) monographs/2O06/RAND*MG21 is not a good idea. Consider,for example,"The night shi.ftis Braun,S. A., & Cox, J. A. (2005).Managedmentalhealthcare:Intenstill not following through with last week's treatmentplan. tional misdiagnosisof mental disorders.Journal of Counseling How is he supposed This to getbetterif we arenot consistent?" and Develoopment,B3,425432. note may stem from legitimate frustration, but a formal Brenner, E. (2003). Consumer-focused psychologicalassessment. progressnotemay not be the bestplaceto air thosefeelings.I ProfessionalPsychology:Researchand Practice, 34, 24014'7. haveread recordbooks that soundedmore like a name-calling Cameron,S., & Turtle-song,L (2002) Learning to write casenotes using the SOAP format.Journal of Counselingand Development, war betweenstaffthan a mutualdiscussionof treatment.Such 80,286-292. notescannotreally be helpful to the clients or the staff. If you Casper',E. S. (1987).A managementsystemto maximize compliance haveconcerns,addressthem with your supervisor,but keepthe with standardsfor medicalrecords.Hospttaland CommunityPsyprogressnotesobjective. chiatry.38. I l9l-l 194. Finally, from the outsetofyour career,developgood note- Claiborn,C. D., Berberogiu,L. S., Nerison,R. M., & Somberg,D. R. taking and record-keepinghabits. Make yourself write notes (1994). The client's perspective:Ethical judgments and percepimmediateiyor as soon after an interactionas possible.Schedtions of therapistpractices.Pro;fessionalPsychology:Research ule the time you needfor notetaking and do not sacrificethis to and P ractice, 25, 268-274. other distractions.Keep your notesas thoroughas they needto Drotar, D. (2000). Training professionalpsychologiststo write and publish the utility of a writer's workshop seminar.Professional be, follow any requiredformat, and establisha processof rePsychology: Research and Practice, 3I (4), 453457 . view to ensurethat you keepeverythingup to date. Given this finding, it certainly behooves the therapist to take the few minutes before a session to review the notes from the last visit. With heavy caseloads and busy schedules, oversights and lapses of memory are almost sure to occur unless clinicians take good notes and then make use of them. On the other hand, clinicians who make efflcient use of progress notes will be more aware of the sequenceof events across sessions. This will lead to better therapeutic care and wili result in higher levelsof satisfactionon the part of clients.

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