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Think of a theme for each session. What was the main focus of that session? Stick only to that. The rest of the information is likely irrelevant. To simplify, ask yourself - Was this central to our treatment plan? Did this lead to a specific insight or breakthrough? Was there something I explained in detail or taught my client? Focus on those key things. The minor details aren't necessary.
Set a timer for 10 minutes and then begin writing your note. If you weren't able to finish one case note in that timeframe, identify where your time is spent so you can begin shortening that timeframe. If you're already at 10 minutes or less then you may be just fine. Realistically, you should plan to spend 10-15 minutes writing notes for a 60-minute session. Less time than that and you're likely not reflecting enough on the clinical content.
Do a review of your notes and identify what was nonessential and could be taken out. Choose one client file and read through six months of notes. You'll likely notice themes of things that stand out as nonessential. Take note of those so you can avoid them in the future. And since you're already doing a review, identify things that may be missing or need improvement. This can easily be done in about 30-60 minutes.
Review six to 12 months of notes and identify common interventions to create a list. This step is a more long-term plan for shortening notes but can be very effective when done thoughtfully. Use your own notes to pull out the things you write over and over across sessions and clients. Then create a list of the common interventions you use with clients that you can pull from for future notes.
Work notes into your scheduled time. If you’re a procrastinator or just too busy to breathe during the day, this one's for you. Set your routine up so that sessions are not done until you have finished your notes. So if your sessions are 60 minutes long, block off 75 minutes per appointment, giving yourself 15 minutes to write notes. Working them into your schedule makes it less likely that you will fall behind, plus you are more likely to remember critical information.
Digitize handwritten notes. Transcribing handwritten notes from your legal pad to a more secure digital space is time-consuming. That doesn’t mean you have to say goodbye to your trusty pen. Embrace technology to help with transcription. Invest in a tablet with a digital pen, like an iPad or some Surface tablets from Microsoft. The reMarkable 2 tablet is designed explicitly for note-taking. These tablets allow you to take notes by hand and then easily convert them to a digital space. Make sure your notes are stored securely, following HIPAA compliance. A platform like TherapyAppointment can store them safely and securely.
Consider Collaborative/ Concurrent Documentation. Collaborative documentation is the act of writing your progress notes alongside your patient. Some research has found that this style of documentation also results in a stronger therapeutic alliance. It also results in shared decision-making for treatment options and even greater accuracy in documentation. Some therapists’ clients actually really like it as it provides a focus period at the end of the session and an opportunity to review future plans. It can also serve as a reminder for therapists to circle back to things they wanted to follow up on but hadn’t had a chance to yet.
Writing therapy notes is an inevitable part of being a therapist, so it’s best to make the process as pleasant as possible. Consider creating a calming ritual for yourself such as making a cup of tea, turning on your favorite music or lighting a candle. Over time, these little rituals will act as cues and will serve to get you into the writing process without much thought.