Idea Transcript
Dr. Rhonda: "The Counselor's Consultant"
The STEPs for Taking Progress Notes Posted on November 20, 2013
Progress notes have always been a bit of a mystery to me, and I have found in the ensuing years since receiving my LPC that I have not been alone in my frustration with taking progress notes. During my early years as a counselor, it seemed that no one had developed a tried and true method to capture the work counselors undertake in therapy sessions with their clients. During my novice, pre-license counseling period, (circa 1997!), when I was on the path to licensure, I was working at a mental health hospital on both the in-patient and outpatient units. The patients I saw were dually diagnosed with severe mental illnesses and addiction problems. Often the other therapists/social workers and the psychiatrists would make fun of the lengthy, in-depth notes I would record in the patients’ charts. I can recall one psychiatrist in particular telling me, with disdain in his voice, that he had read the “story” I had written about a particular patient. Although I felt both inexperienced and slightly incompetent at the time, I found it extremely important to recall all I could in those notes so that the doctors and other mental health workers could get an accurate “picture” of what I saw going on with the patient. I wanted to make sure I recorded the facts, the behaviors of the patient, and any other information I thought pertinent as helping the person was the main goal (right?). Also, didn’t one need as much information as possible to be doing their best as a counselor? I honestly had no way to conceptualize the session, so I would write and write and write. Later, when I started my own private practice, I suddenly had concerns about how much I was writing in my progress notes. One reason for this was due to conversations I had with other therapists. For example, a clinician who had worked at the mental health hospital with me had her own private practice and she was, in my opinion, a seasoned professional. She told me that she wanted to make sure that she was never sued, so she did not keep any notes on her clients. I was somewhat horrified by this idea as it seemed to be a rather unethical approach to documentation (or should I say, lack of documentation?). So, I did keep notes but was always rather concerned about capturing too much or too little. It also seemed to me that as a counseling profession, we should take this whole idea of notes seriously since this documentation reflects the essence of what we do as mental health providers. However, I had never received formal training on how to take a progress note. Therefore, I did some of my own research and came across the “SOAP” method; so, I attempted to adapt that medical model to my own practice (subjective, objective, assessment and plan), but it never quite fit. Within the last two years, two important incidents have inspired me to focus more on progress notes. The first incident, which has actually occurred more than once, has involved the supervision I offer LPCAs. Specifically, I have had a few supervisees ask me, “How do I take a good progress note?” Supervisees have shared with me their own frustrations with how to document their clients’ progress as well as how to apply what they do in clear terms within their notes. The second incident was when I was subpoenaed. Let me first say that this was a very uncomfortable and worrisome experience! I was concerned about my notes and how these might be scrutinized if I had to turn them over to the attorneys. Fortunately, I did not have to do so, but this encounter with the legal system definitely showed me the need to think clearly and methodically about the way in which I document my clients’ progress. For these reasons, as well as due to my firm belief that as counselors we need to impress upon others the importance and significance of the work that we do, I have created a step-by-step process for taking therapy progress notes: STEP NotesTM. A Little More About Progress Notes and Their Importance to Counselors In terms of thinking about progress notes, it has become apparent to me that these notes are vital to the work of counselors and other mental health providers. Progress notes serve as a way to evaluate the course of therapy, determine what is and is not working with the client, and monitor the impact of the counseling interventions as well as the functioning of the client. Progress notes document when and for how long a client was seen and establish a record of the therapy the client received. Whether the progress notes serves as justification for insurance payment, documentation utilized in legal proceedings, or a record for the counselor to review prior to the next session with the client, these notes are, without a doubt, essential undertakings for all counselors. Having a consistent, streamlined way in which to take progress notes would be a great benefit for the counseling profession. For me, I know I also work best when a system is simple! So with all this in mind, I thought through the “steps” in STEPnotes and got feedback along the way from other counselors and counselors-in-training (and am very grateful for the time they took providing me with their perspectives and input). The STEPs to Taking Progress Notes The “steps” in STEP NotesTM provide the underlying structure for the progress note along with a solid foundation for how to assess, evaluate and plan interventions and goals for clients. Following is the general format for STEP NotesTM: “S” indicates the SUBJECTS the client discussed and the SYMPTOMS the client either reported or exhibited. Examples of subjects include depression, anxiety, relationship problems, school problems, self-harm, or other topics that the client shared. Important aspects of the subjects discussed include the ability to see if the same subject is discussed each session or if new ones arise. Symptoms include emotional, behavioral, cognitive and physical symptoms. Emotional symptoms may be anger, elation, frustration, or sadness. Agitation, spending more money, and eating less are examples of behavioral symptoms. Cognitive symptoms may include irrational thoughts or confusion. Physical symptoms may include back pain, neck tension, or ulcers. Counselors needs to monitor the symptoms and see how these either decrease, increase or manifest over the course of therapy. “T” refers to the actual THERAPEUTIC TOOLS the counselor utilized during the session with the client. For instance, did the counselor use cognitive-behavioral therapy, narrative therapy or reality therapy? In addition to the actual therapeutic approach, what did the counselor actually do in the session with the client? Counselors need to use action verbs in order to note the work that they undertake with their clients. Words such as, “aligned, demonstrated, explored, illustrated, reframed” are all examples of action verbs that can start a sentence which describes how the therapist put into practice the theoretical approach that was applied. “E” indicates the EVALUATION section of the progress note. Evaluation involves the client’s level of engagement in therapy; for example, is the client minimizing, open or guarded? Evaluation also needs to include an assessment of the client’s current level of functioning. This assessment is of particular importance when working with clients who share suicidal or homicidal ideation as well as serious concerns involving depression, anxiety, hallucinations, delusions and poor self-care. “P” is the last part of the progress note and references both the short- and long-term PLAN for the client. The plan may include the homework assigned, interventions that are currently being undertaken, and the long-range goals the client needs to meet in order for therapy to conclude. The plan can also include topics or other details that came up during the session that were not addressed in the current session but that the counselor wants to make sure to follow up on during the next session. More information about the “STEPs” as well as a paper version can be found in the book: “STEPnotes: The Counselor’s Guide to Progress Notes” which is available in both print and e-book formats on amazon.com at: amazon.com/author/rhondasutton Hopefully the “STEPs” will provide mental health, school and career counselors with the format they need to systematically and clearly document their counseling sessions. It is the goal of STEP NotesTM to provide a professional and thoughtful conceptualization of therapy sessions, and to become a useful tool for how for counselors note the progress of their clients.
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About drrhondasutton Dr. Rhonda Sutton is a licensed professional counselor and counselor supervisor with over 25 years of experience. She provides supervision to LPCAs and serves as an adjunct professor in the Counselor Education Program at North Carolina State University. Dr. Sutton is the author of "The Counselor's STEPs for Progress Notes: A Guide to Clinical Language and Documentation" which is available on Amazon.com at http://www.amazon.com/. She is also the president of STEPnotes, Inc., (www.stepnotesinc.com/store) a business which offers a unique, efficient method for taking progress/therapy notes through its book, downloadable forms and e-tool. Dr. Sutton is "The Counselor's Consultant," providing support and guidance to counselors in regards to their work with clients and their own professional identity development. View all posts by drrhondasutton Õ
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One Response to The STEPs for Taking Progress Notes daynasykeslpc says: October 30, 2014 at 11:16 pm
Thank you for this post! I have been a counselor for 11 years and used to work in a company where we had to document EVERYTHING in our notes with much detail. However, I now have a private practice and am trying to unlearn that skill. This was very helpful as I have been doing research for a couple years now and trying to find the best format and examples as I am a visual learner and have not found any good examples or explanations on how to tone it down a bit. Reply
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