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Practice Management Blog

What Not to Do When Taking Mental Health Progress Notes

Taking good mental health progress notes is essential for helping clients through to the best outcomes, your own reference, and protection, as well as for other clinicians who may need to view the notes. But with so many different choices – digital versus hard copy and full detail versus concise, it can be difficult to know what to include and what to leave out. Let’s take a step back and look at the purpose of progress notes when it comes to mental health, and from there we can look at what not to do (which is often just as important as focusing on what you should be doing).

To get an on-the-ground perspective, we chatted with Power Diary founder and psychology practice owner, Damien Adler, to get his thoughts on the best way to tackle mental health progress notes based on his years of experience working in the field.

What are Mental Health Progress Notes?

These are the notes that a clinician (such as a psychologist) takes during a session with a patient. In general, they will be relative to the treatment plan as well as including notes of relevant incidents that arise during the treatment episode. They should include specific information about interventions and responses.

Mental health progress notes are clinical observations and, as such, they should not contain opinions or judgments, rather they should cover the clinician’s interventions, the client’s responses and the noted change (the results of the interventions and responses).

Progress notes will, in many cases, be shared with other clinicians who are assisting with a patient’s treatment plan. They are, therefore, integral in communicating information such as current patient care, treatment plans, and medical history so that other healthcare professionals don’t need to start from the beginning each time they meet with a new patient.

The most common note-taking methodology is based on SOAP, and should address these four components:

  • Subjective: the patient’s current condition as they describe it;
  • Objective: findings from a physical examination;
  • Assessment: summary of the patient’s diagnosis;
  • Plan: treatment for the patient including referrals, lab order, a review of medications and any other relevant follow-up information.

From Damien’s perspective, it’s not so important to focus on following a strict methodology, because there’s no ‘one right way’ of doing things. But most clinicians will loosely follow the SOAP method as it offers a structure, but this varies from country to country, and between practices. For him, the key thing is that notes have a structure, not one long narrative and that the structure is used consistently.

What are the Top 7 Pitfalls to Avoid?

There’s always a debate amongst therapists about how much information is too much, specifically what should be included in progress notes, and what constitutes “fluff”. The right decision will depend on your personal preferences, and your practice setting, but there are seven pitfalls that you should avoid:

1. Don’t Keep Illegible, Handwritten Mental Health Progress Notes

Digital notes are the best solution in today’s online world because they ensure the notes you take are legible and stored safely (if you use practice management software such as Power Diary). Clear, digital notes mean that:

  • You can read your own notes and can offer your patients the best level of care;
  • Other clinicians can review your notes if, for example, your client moves to another city;
  • Your notes are safely stored in the cloud, so you can easily reference a past client or continue with note-taking even if your physical notes are destroyed (in the event of a fire or theft).

In the past, clinicians were sometimes encouraged to write notes that were difficult to read (even illegible) in order to protect themselves against potential legal action. The thinking was that if there was a government review and you had to go to court to give evidence, or if there was a review by your professional standards body, you could say anything you wanted because no one could read what you had written! This meant, of course, that they wouldn’t know what course of treatment you had decided on in the first place. But this kind of thinking doesn’t hold water; it’s incredibly frustrating for the people who are trying to decipher your notes and will make them less likely to trust you as your obfuscation will seem deliberate. In most countries, there is a state requirement that the mental health progress notes you take must be readable by others and, if you don’t, it’s a breach of standards.

There are still many practices that haven’t taken their progress notes online, and it does a disservice to your clients as well as other clinicians who may need to refer to your notes in order to make fully-informed decisions about your patient’s care.

An Experience-Based Professional Insight:

To illustrate this point, Damien shares a practical situation where this happens all the time: when a clinician becomes unwell. If one of the clinicians in a mental health practice becomes ill and another clinician has to take over their (often heavy) caseload there is potential for inefficiencies to creep in, and there could also be serious consequences. In this example, the new clinician might have to cover old territory with the client and make repeated contact with the sick clinician to verify the points they made in their notes. But this could go one step further and have legal implications if the new clinician were to miss something important that was in the notes, and there was an adverse patient outcome.

2. Don’t Use Vague, Flowery Language

Your clinical notes should always be concise and specific. Don’t include details that aren’t necessary such as descriptions of incidents that took place in the patient’s past when a sentence or two can summarise what happened adequately. But being concise doesn’t always mean being brief. One thing you will want to remember is to cover any important information that is relevant for explaining your treatment approach.

Specificity is also helpful, rather than simply noting a diagnosis, such as depression, you can also include specific symptoms which works to keep your notes focused on facts rather than interpretations. This helps to protect yourself legally in court and with licensing boards or professional organisations, especially if you describe the client’s struggles, the steps you took to resolve the issues and the reasons that you took the steps. It also helps other clinicians if you are working together and making joint decisions about a patient’s treatment plan.

An Experience-Based Professional Insight:

As Damien notes, the key benefits of keeping concise focused notes are that you always know where you are with each client. It happens all the time that our busy lives and a large caseload mean that you don’t have all the facts right at your fingertips. But this can be instantly addressed with clear mental health progress notes that allow you to recap the most important information in moments.

3. Don’t Take Shortcuts

Every time you make progress notes for a patient, you should include your full name, date, time, patient name, and patient identifier and your notes should be signed electronically. There is both a legal and an ethical component to this, especially when there are other clinicians involved in the treatment of a patient.

An Experience-Based Professional Insight:

The importance of this can’t be overstated, especially if the worst-case scenario happened and there was an adverse client outcome. Here, it is possible, even likely, that your notes would be reviewed by a standards committee. If they were found not to adhere to professional standards, this might reduce your standing and bring into question your conduct. The thinking here is that if a clinician takes shortcuts in their notes, they may also take shortcuts in other areas of their work, such as fully assessing and evaluating risk.

4. Don’t Summarise if the Patient is Suicidal

Full details are important if you are treating a patient who is suicidal at presentation. Here, your notes should have clear, carefully considered explanations for your decisions, including if you discontinue any suicide precautions or fail to refer for further risk management. These notes will be essential in the event of an adverse event such as a suicide attempt after an appointment. You should always ask the patient if they have considered suicide and consider the background risk factors (such as social and family circumstances as well as any previous suicidal behaviour) in addition to their current presentation.

An Experience-Based Professional Insight:

This is the worst-case scenario, but the suicide of a patient is one of the most likely events to trigger a review of your clinical decision-making. Your mental health notes are your primary defense that your actions were reasonable and well-considered.

5. Don’t Name or Quote Individuals Unless Essential

If a third party is not essential to your patient’s records, don’t name, quote or identify them specifically as this can lead to unproven allegations and privacy violations. Whilst notes are subject to client confidentiality, they can be read by other clinicians in some circumstances, subpoenaed, reviewed by lawyers and solicitors, and can even be read aloud in court. This means that there could be serious implications when you include identifiable details related to other people as it could damage their reputation, cause additional conflict or even put them at risk.

Additionally, some clients may ask you to restrict your record-keeping so that others won’t have access to the information further down the road. This means that you will have to make decisions about the notes that you keep and the level of detail you go into so that you are:

  • Protected as their treatment provider;
  • Compliant with your professional obligations;
  • Respectful of your client’s wishes;
  • Able to provide and coordinate the treatment they need.

It can be difficult to juggle these, often opposing considerations, but compliance and client care should be the two most important considerations.

An Experience-Based Professional Insight:

There are a number of circumstances where it may be important to not record identifying details. For example, if a client were disclosing their involvement in a crime that involved other perpetrators. Damien suggests that in this instance you would write about the person’s symptoms, such as sleeplessness as a result of being part of a crime, but omit any potentially unnecessary details of the actual crime such as location and other parties involved. At this point, you may wish to communicate to your client that you aren’t taking down the details in your notes, as well as requesting them to describe the situation as it relates to their issues while leaving out the specifics.

6. Don’t Use Your Own Shorthand

Depending on your clinical setup and the patient’s treatment requirements, it may be necessary for other clinicians to review their charts. This makes it essential that your notes are up-to-date and easy to read. Many clinicians develop bad note-taking habits over time, including an informal shorthand that they use in their mental health progress notes. This should be avoided at all costs as it makes it confusing (and possibly time-consuming) for others who need to work from your notes. Here again, digital notes can make your life a lot easier.

An Experience-Based Professional Insight:

It’s fine to use recognised, endorsed shorthand for your profession and location. But stick to the conventions to ensure that your notes aren’t misunderstood because this could have negative consequences where a misinterpretation leads to incorrect treatment interventions by other providers.

7. Don’t Forget Legal and Other Binding Requirements for Your Mental Health Progress Notes

Your patient progress notes need to include information that is necessary to keep you compliant with legal regulations as well as meeting third-party contractual requirements. They should also reflect your commitment to offering your clients quality care, as well as your decision-making process for high-risk situations. The notes should also allow for collaboration with other professionals and meet the requirements of your practice setting.

Phew! That’s quite a long list of people that you need to keep happy.

An Experience-Based Professional Insight:

A quick checklist can help ensure that your mental health progress notes are comprehensive and compliant, consider:

What’s the Best Option for Mental Health Progress Notes?

Keeping accurate mental health practice notes can be a minefield and moving from a handwritten to an electronic solution is often the best solution. Electronic notes reduce stress, save time, and ensure that you stay compliant. The transitioning process can raise some concerns, such as what to do with the existing notes and whether it will affect your sessions with your clients. But once you make the move you’ll be surprised how fast and efficient it is.

Adopting practice management software for mental health progress notes can be as simple as 1, 2, 3:

1. Decide What to Do with Handwritten Notes for the Current and Past Clients

Using practice management software you can scan and upload entire files as a single attachment (not one-by-one). You can then either:

  • Scan in existing notes for your current clients and simply archive past client notes,
  • Set a cut-off on a specific date, and proceed with electronic notes from that date forward, and not scan in any handwritten notes or,
  • Scan all existing notes from all past and future clients, so all records are in a digital format.

2. Get Set-up with Electronic Mental Health Progress Notes

Create templates for your electronic notes (or use existing templates from the practice management system’s library – Power Diary comes with 100’s of customisable templates).

3. Start Taking Notes

You’ll be amazed at:

  • How easy it is, to use the technology, once you’ve done one or two sessions.
  • The amount of time you save, no more evenings spent catching up on client notes.
  • How helpful the framework is, working off a template is an excellent way to ensure that you cover the most important points of a session, without forgetting anything.

However you choose to make the transition to electronic notes, you’re going to see significant cost and time-saving benefits, including:

  • Reduced storage and archiving costs – it’s all stored on a remote web server, so the physical copies don’t need to keep gather dust in storage.
  • Secure back-ups, cloud-based practice management, fully-secured software means that you don’t have to worry about locking your notes away or the risk of fire and other damage.
  • Easy access, wherever you are, you can immediately access your client notes, as long as you have an internet connection.
  • Print options, if you need to provide a copy for legal purposes or an insurance claims, you can send through the records at the click of a button, no more tedious photocopying and scanning. Even if you only get one or two requests a month, it can quickly add up to a significant time-saving benefit.
  • Client record requests – with freedom of information in many jurisdictions, patients can request a copy of their file at any time, and with electronic notes, you can generate a copy quickly, without need to spend an hour at a photocopier.

In Summary,

Electronic mental health progress notes are the ideal way to improve your note-taking and will give you the best chance of avoiding the seven pitfalls that can impact the quality of clinicians’ notes. If you’re mindful of these tips, you’ll be well on your way to keeping notes that are clear, concise and helpful for you, your patient and other clinicians.

If you know a mental health practice owner who is struggling to manage note-taking within their practice, please send this article through to them. The risks associated with poor or inadequate progress notes mean that this is one area that all mental health providers need to be at the top of their game.

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