130
CsRprrR6
HIPAA guidelines about electronic
data storage,communica-
This
This might
might feel
feer honest
honest ar
and
rd cathartic,
cathartic but
tion'andsecuritv
h,r it
it could
a^,,r: get
-^. you into
aresoexplicitand,alongwithspecifvinetr"*ri"r"r"..
frorrhrelo+a_rf
rr yo;
-,^_-;;.;#f:T
tempte
what information can and cannot be exchanled,
d
to
make'
#:t;:Tt"iT#
; ;;; ;;
TJ
include meal yo-urreri
::::,:::I i,',::
l:.",it1','
wirat-'1
good
" " own
,..u.r'toto wrire
serves
eooa
write in
in your
your
andencrvption
own nores
notes rhat
toprotect
tha,
againsthack-l::t:::l1t
ll
vulrJ,
or^
ra !vrwD
ttl4t
-
you know
roJ^-uo" uneror.
*o.. you
tno, itrt yourr"lf,
yourself,uni
and,rru,
rhatis suffi_
suffi:,."^:.-:t
crent. Remember
-
".rHTffiiffifiT
rrqL
rJ
bulll_
the advice your auto i";;':"
insurancecompanv
q"".31,'"
company
gives
ff:: j:T:T:1':-io"'"'
you
pRorrcrlrucyounselr
if you are in an accident.Ir
somethin,*i""r*r",.
#"H::'HT:".1*.;::*ffil.1""T,li:il::'ij'i,i"::::
;;i[1,,#,:T:",l.;',.;'run:i';
yourself' No clear-cutrules exist in
this area,but interns and
tffi;;;iasfy
recoras.ff your recordsare demanded
clinicianswould do well to askthemselves
how what theyput in for a legar p.o.""aing,
y", ,rtt be askedunder
recordsmight later soundin a court proceeding'
oath if your
Gutheil (i980) recordsrepresenta trueand
accuratedescriptionofyour trearment
went so far as to suggestthat trainees
orhavebeenarteredin;;;;"""
theywereoriginaly written.
j+"g1**::;#ff
;:x1""'il:#:il4li.iffi'ffi
*H#g,*hy*
[,,t,,..J,T:;H:,rT:il::;riill
"uppinJ*'.
that
to thisvisualhallucination
tt
if youare
- - ' uoarto.y
imp."r:t-ntouslv honest
sion
orthevoice
most
suited
toi,."v
""".;;"ni:t::,#ti#i:Tll13
work
with
rour
rp.iarj
u.t"n,rou
,"",,r"TLtl i?3f,"TJ,.iH:n#*.
tt*"
Gutheit
(1e80)
r:u:,*:,".thedeficiency
continued,
saying:
rJ: :ffi?:tl jl[L]li;l'.T:
coverecl
somethingthatneededto be added
o. .rr*g"Ji i;;
lier note'This doesnot meanyou
go backunau.ruur! .rrur!" "._
tir"
Havingachieved
this goal-directed
transienr
ps1
,rainee
shou,d
;:::.1;:il:,';ff;::.J;r;rilf,.;:tharindicares
whatheorsheisabouttowrite'
".,;i::i#T:J:1jlx"T:i:il'JrT:"'jjrJi;
(p 481)
For example, suppose that
two days
after you
rhisdoes
notmean
thar
youshould
berrightened
about.#fli?lT:#:ij::;l::Ji,fi1T:X;:,,*"Sf
wrote an
iJil'l;ii"',:i,T:",ll,"{lJ::f,*:ffi'.il*'.1X.;;x1
beadded
o,,nu,''o,-,,"nt,
write
rhe
present
date
;{,j?i".,.
j:";"i#It*:$.ffi
:H:::#i.ffi
i;il"?.ffi
:"tl*:'lni
jltlFT:x."J,':;*:"{
"Ltr;*
yourrreatmenr
anddocumentation
atthehighest
revel::":,r,y: i"r"i **r""ions
Keep in mind' too' that under
arise.
x;.1_r?ir"i";rxi::
urnei t"iottines' clients
uft=er
un unfortunate
have accessto their ow
""*..,,J,
*" noiirkely to cany asmuch
are.protected
ir r"pt,.pJ.ffiT;,1itl
;:ilHtffitt;::T
thatis accessible
to clients
weishr
"u.n,
t;;;; t""uu,"they
rend
robeseen
asserf-serving.
uponrequest,itls advisabieto
recordingyour own emotionrt..".,,^--'" avoid
'""'"
^-"^ -".*]''
i*il*ft Ti"Jil".:*f
;:{:::#n""',il',T'":":,1iFg9.",f"T;lh^
Froma lJabilityrisk_management
per.spective.
rwo things
,.raising
Exrnclsr
ghosts,;
unj
iurin,
IE;
urd'c' By
brame.
__<
fty
il,lJ"'.*:::"io:11:
raising
ghosts, I mean recording
unfounded o unnecessary
If you are working in a clinical
speculationin your notes.For
setting,find out if you can obexample,if a client seemsa
bit tainpermissiontorev.iew".-^^rr"^^^+:^-.
down durinqa-"""";^- *,,n."^-^ ,
-
;ft'J.:H:::*1fi!T"':#i::ji;J;ff
f,#UXJ,'J':l:[:lT:jT:;:t*:+#",:-T+[
wourd
beunwise
roraciinicia,,
to.""o,Jrc;;;ilJffH;f
lil:ri"?::;[Td;JJ,ffi1***n:*::i:*itm:
'"1l:i;;Jlj**.nm,x;
;i"1"i,::io|3ff":lfjt
ma,,ers
ors,v,e
uno
inro,-uiion
u.*ffiiln::H*,lJJ#,
documentthat you did so.
If suicide.irt i, noi.f"vated quw vc
above
normal, do
n o t m e n tio n it a t a ll T h c o o - o ._ ,^ ._ ;; ^ , . ;'.u
_
rerating
. 0",r".";**'#i
X"lllJiiJT".L,nr
srANDA
about somethingso serious {:i:H'
RDFoRMArs
in your
,"r"r, irou followed
up
on thatspeculation
""",
duringyour session.
A.secondthing to avoid in
recordsis takin
notwritein vournJtes
thatyou;;;;JilJ1:ffi#
-
In an effortto standardize
treatmentnotes,manyagencies
have
or adopted
ror*n", .,,"r,0,,
n'"".:'Ttnotes.This is'n"oo"'r"to"rines
very important
in medical settinssor
-
RrcoRos,AND
CnsrNores 131
Ct-ttttcRrWRmNG,TREATMENT
lnto
ask
that
rffiany
rate
our
our
led
cur
ent
9n.
of
)ur
re
lu
he
sle
n
tt
l
t
I
I
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
132
Cnnprrn6
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
|l
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,
mfl"'
ji
:r : i
134
CHnprpn6
October 20, at 4 p.v. If further concerns arise before then,
we will call and inform him.
T:
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
i.
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,
136
,ti
!.
CHnpruR
6
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.
tqllil
'
-1
ll
138
CHaprrR
6
Fischel C. (I99q. IndividuatiTedp sychologicalassessment.Montercy. Rupert,
P.A., & Baird, K. A., (2004).Managedcare and the indepen_
CA: Brooks/Cole.
dent practiceof psychotogy.professionalpsychology: Research
Fox, R., & Gutheil, I. A. (2000).processrecording:A meansfor conand Practice, 35, IB5-193.
ceptualizingand evaluatingpractice.Journal ofTeaching in So- Shaw,M. (1997).
Charting made incredibty easy.Springhouse,pA:
cial Work.20,39_5i.
Springhouse.
Grayson,H. M., & Tolman,R. S. (1950).A semanticsrudyof concepts Siskind,
G. (1967). Fifteen years later: A replication of .A semanric
of clinical psychologistsand psychiatrists.Journal of Abnormal
study of conceptsof clinical psychologistsand psychiatrists.,,
and Social Psychology, 45, 216-23 1.
Joumal of Psychology,65,3_j.
Gutheil, T. G. (19S0).Paranoiaand progressnotes:A guide to forensi- Soisson,E. L.,
VandeCreek,
L., & Knapp,S. (19g7).Thoroughrecord
cally informed psychiatricrecordkeeping.Hospital and Commu_
keeping:A good defensein a.litigious era.professionalpsychot_
31,479482.
. nity Psychiatry,
ogy: Researchand practice, jB, 499_502.
Harris,E. A. (1995).The importanceof risk managementin a managed Steinfeld,B., Ekorenrud,
B., Gillett,C., euirk, M., & Eytan,T., (2006)
care environment.In M. B. Sussman(Ed.),A perilous calling:
EMRs bring all of healthcaretogether.Behavioral Healthcare,
Thehazardsof psychotherapypractice (pp. 241-25g). New york:
26(1),12_17.
Wiley.
Shunk, W., Jr., & White, E. B. (2000). The elementsaf style(4th
ed,.).
Hartiage,L. C., & Merck, K. H. (191I).Increasingrhe relevanceof
Boston:Allyn & Bacon.
psychological repofis. Journal of Ctinicat psychology, 1971,
Tallent,N. (1997).psychologicalreport writittg (4thed.). Engiewood
27(4),459460.
Ciiffs, NJ: Prentice-Hall.
Harvey,V. S. (1997). Improving readability of psychologicalreports.
VanVort,W, & Mattson,M. R. (19g9).A strategy for enhancing
the
Professional Psychology; Research and practice, 2B,2j 1_2j4.
clinical utility of the psychiatricrecord. Hospital and Community
Hodges,J. C., Horneq W. B., Webb, S. S., & Miller, R. K. (1998).
Psychiatry,40, 4Oj 409.
Harbrace collegehandbook(l3th ed., rev.). New york: Harcourt
VandenBos,G. R. (Ed.). (2006)ApA Dictionary of psychotogy,
Wash_
BraceJovanovich.
ington,DC: Americanpsychological
Association.
Jeffords'J. (1999). confidentiality of medical information: protecting
Wedding,D., Topolski,J.,& McGaha,A. (1995).Maintaining
rheconprivacy in an electronic age.professionalpsychology;Research
fidentiality of computerizedmentalhealth outcome data.Joumal
and Practice, 30(Z), 115-1 16.
of Mental Health Administration,22, 237_244.
Kagle,J. D. (1993).Recordkeeping:Directionsfor the 1990s.
,Soctal Weed,L. L. (1971).Medicalrecords,med.icaleclucation,
andpatientcare:
Work,38, 190-196.
Theproblem-oriented record as a basic tool. Clttcago:year Book.
Piazza,N. J., & Baruth,N. E. (1990).Clientrecordguidelines.
Journal Wiger, D. (1999). The clinical documentationsourcebook;
A compre_
of Counselingand Development,68, 313_316.
hensivecollectionof mentalhealthpractice
handouts,
and
forms,
Piercy,F. P.,Sprenkle,D. H., & McDaniel,S. H. (1996).Teachingpro_
records(2nd ed.). New york: Wiley.
fessionalwdting to family therapists:Three approaches.
Journal Zinsser,W. (1993).On writing well: The classicguid.e
to u)riting non_
of Marital and Family Therapy,22, 163_1'19.
fcllon. New York: Harper.
RAND Corporation(2005). Healrh information technology:Can
HIT
Zuckerman,E. L. (2000). The clinician's thesaurus:A guidebookfor
lower costs and improve quality? http://www.rand.org/pubs/
wording psychological reports and otl.rerevaluations(5th
ed.).
research_briefs/RB9
136/indexl.html
Pittsburgh:ThreeWishespress.