Writing clinical notes is an inescapable reality for healthcare professionals. And you’re not alone if you work at night, trying to catch up on notes from the day’s appointments.
But have you considered that there might be better ways to tackle the task of note-taking? That you could get the process down to five minutes per client?
Help is at hand! If you struggle to take notes quickly, with or without EHR software, it’s time to turn that all around with a tried and tested method for quick clinical note-taking. In this article, you’ll get proven strategies to streamline your clinical note-taking significantly, and the tools you need to make it happen.
How To Write a Clinical Note
Clinical (or progress) notes should concisely reflect the client’s treatment and progress. Clients or other treatment providers may request access to your clinical notes, and they could be used in legal proceedings. This means you should construct clinical notes professionally and from a neutral perspective.
When you use the right approach, writing a clinical note shouldn’t take much longer than 5 minutes.
So, what makes up an excellent clinical note?
The Contents of a Clinical Note
Here’s what you need to include:
- The session date
- The client’s name
- The session number
- Whether the client showed up for the session
- Intervention methods applied
- Treatment goals
- Your observations during the session
- The client’s response to treatment (progress)
- A diagnosis
- A follow-up plan
- Your name and signature
But wait: isn’t that too much information to record in just 5 minutes? It can seem that way, but don’t be intimidated! Read on for the strategies that make this possible.
First, there are a couple of mistakes you need to avoid when you take clinical notes.
How Not To Take Clinical Notes
Even though there are effective ways to reduce the time it takes to create clinical notes, you don’t want to be in so much of a rush that errors creep in.
Here are some tips to avoid making mistakes:
- You don’t know who will be reading your notes in the future. Stick to clinical language as far as possible, and avoid using shorthand which could be hard to interpret later.
- If your client presents with a risk of self-harm, document this, together with both risk and protective factors as well as any plans implemented to manage this. If no suicidal risk factors are present, note this as well, as it demonstrates that you’ve assessed this.
- To protect yourself legally, avoid using names that might identify third parties in your notes.
- Adhere to any local legal requirements that apply to your note-taking as a clinician, and don’t make false statements.
How Can You Write Clinical Notes Faster?
Here are five impactful ways to speed up the writing of your clinical notes:
1. Use a Standard Format
Using a set structure for every clinical note you take is wise. Once you’ve used the structure a few times, you’ll know the format by heart. This is the first way to shave time off note-taking.
There are commonly accepted standard formats, such as SOAP notes, DAP notes, and more, to use to your advantage.
2. Use Standard Terms & Phrases
When you create a “library” of standard terms and phrases and train yourself to use these when completing clinical notes, you’ll reduce the need for your brain to think of useful descriptions every time you create a note. For example, you can create a standard list of intervention methods, treatment approaches, symptoms, etc.
Of course, this doesn’t negate the need to pay attention when completing notes. There may be exceptions when your list of commonly used terms and phrases doesn’t cover a situation, and then you must think of the appropriate language to complete your note.
3. Simplify Your Template
There’s an ingenious way to simplify the note template you use. It’s so simple that many clinicians haven’t thought of it. So what are we talking about?
For some of the standard information recorded on a clinical note, there are only a few possible answers. This is where checkboxes are your best friend. For example, if you want to indicate whether a client showed up for a session, having a “present” and “not present” checkbox on your template is much faster. You only have to tick one, and there you go. No more manual writing (or typing) “present” or “not present”.
Other examples where checkboxes may come in handy and save you time include intervention methods, treatment goals, and diagnosis.
4. Take Notes During a Session
If you take notes during a session, you no longer have to set aside extra time afterwards for note-taking! It might take a bit of getting used to, but you’ll get comfortable doing it with practice. When you choose to do this, however, remember that you should keep the client engaged during a session.
For instance, when it comes to treatment options, there’s an opportunity to get the client to come to an agreement on the chosen methods, which can encourage greater cooperation from them. In addition, when you summarise the notes you take aloud, it allows the client to provide input. This means that when you write clinical notes during sessions, it’s almost a given that the accuracy of the data will improve. Not only can the client provide input, but you also won’t be required to recall information once a session is complete.
You may still wonder how you can take notes without disrupting a session. This is where EHR software becomes an indispensable tool. It makes the note-taking process seamless and unobtrusive instead of hindering it!
5. Know Your EHR Software
EHR software is probably the most effective way to slash the time you take to create clinical notes. The trick, however, is to make sure you know what capabilities the software offers. You should also decide whether to use the software on a PC, laptop, tablet, or cell phone during a session.
Power Diary has been developed by clinicians for clinicians. This means it enables a remarkable improvement in running clinical practices efficiently, including having several practical note-taking features.
Create Clinical Note Templates (Quickly!)
Creating clinical (or session) note templates within Power Diary allows you to include anything from text inputs and drop-down menus to body charts and drawings to use during a session. This means you can include your library of standard terms and phrases in your note template, and simply select what you need from a drop-down menu on-screen during a session.
Import Clinical Note Templates from Power Diary’s Library
Creating a clinical (or session) note template within Power Diary is made even easier because of the comprehensive library of built-in note templates you can import and configure to your liking. It eliminates the need for you to devise comprehensive note-taking methods all by yourself!
Copy Session Notes
When clients come to you for a series of sessions, it sometimes happens that there aren’t many new developments between one session and the next. In cases like this, Power Diary allows you to duplicate previous notes so that you only have to make edits where changes apply.
Handwrite Clinical Notes
If you’re a firm believer in writing notes by hand, you can do so while using an electronic device. This means you won’t have the two-step process of recording your notes manually and then importing them into your EHR software.
You can do this by using an Apple Pencil on an iPad to write your notes, and the software will convert your writing into typed text. Another option is to use a device like the reMarkable 2 tablet.
Dictate Clinical Notes
Some clinicians dictate their notes with great success. To try this, check out Power Diary’s guide for using speech-to-text to record session notes.
Write Clinical Notes Faster With Power Diary
We trust this guide has shown you that your valuable time doesn’t have to be taken up with hours of note-taking. Sign up for a free trial today to experience just how revolutionary Power Diary can be for your practice!