However, most therapists fear documentation.
Whether that’s fear of being subpoenaed, fear of being audited, or even fear of having your lack of notes “discovered.”
We are taught to fear documentation. Through not talking about it, through lack of training and through poor supervision. You are implicitly told your documentation probably isn’t good enough but don’t ask too many questions or you might be reported to the licensing board.
Well, I am here to change all that. First of all, we’re talking about it! And that’s half the battle. Now, I have some easy tips for you to overcome your fear.
One of the best ways I’ve found to do this is by discovering exactly what is going on and tackling it head-on.
Take a moment to stop and reflect on what it is like when you sit down to write notes. Picture one of your clients. Picture yourself right now, about to start typing (or writing).
How many notes do you need to write? It may be a long list of catch up or it may simply be 1-2 notes for a recent client.
Now consider this: How do you feel? Are you nervous, resentful, anxious? Overwhelmed?
If so, take a moment to write down what those feelings are and why. Did you have prior negative experience with documentation? Were you chastised by a supervisor or overwhelmed by paperwork requirements at an agency?
We all know that when people are emotionally triggered in a negative way they have difficulty solving problems and thinking rationally. Think about what that means for writing notes!
When we associate documentation with everything that’s negative we will inherently have more difficulty writing quality notes and making clear decisions about what to include. Acknowledging these past negative experiences is crucial to creating a new reality and forming a different relationship with documentation.
Now I want you to take a few moments and reconsider that same situation of sitting down to write notes. This time imagine yourself as a “writer.” You do this for a living because you love it. You are creating meaning from people’s stories. You have the privilege of writing out their journey with you. Your fingers fly with ease. In this scenario, were you able to put yourself in that role? Could you see yourself as confident and competent? Did it feel different?
Now let’s apply this to your every day (work)life.
Perhaps there is an area in which you feel more confident. For example, maybe you have trouble staying on top of writing notes but you are very comfortable with your policies and procedures. Identify and acknowledge this! Write out your strengths, everything you’re good at clinically. How can this apply to your documentation?
For example, if you’re really good at building rapport you can bring that into your documentation by creating an awesome intake session. You’re probably able to easily navigate the conversation and make people feel comfortable so it’s not just a session about signing forms.
I call that creating a conversation out of your paperwork. And that’s really all documentation is- the written versions of the conversations you have with your clients.
So let’s change our experience of documentation by actively making it a more positive experience. I challenge you to share this with a colleague. The more we talk about our experiences and share information, the more we will create that positive reframe.
Who knows… you may discover documentation isn’t so scary after all.
Bio: Dr. Maelisa Hall specializes in teaching therapists how to connect with their paperwork so it’s more simple and more meaningful. The result? Rock solid documentation every therapist can be proud of! Check out her free online Private Practice Paperwork Crash Course , and get tips on improving your documentation today.
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