Show Notes

Welcome back to The Designer Practice Podcast, and I’m your host, Kayla Das.

In today’s episode, Simren Sidhu, lawyer, Canadian certified counselor and registered clinical counselor will share simple strategies to prevent professional complaints in practice.

Hi Simren, welcome to the show. I’m so glad to have you here today.

Hi Kayla. Thanks for having me. I’m excited to be here today.

Simren, before we dive into today’s episode, please introduce yourself, where you’re from, and tell us a little bit about your professional journey.

Yes, so, as you said, I am a lawyer, Canadian certified counselor, and registered clinical counselor. I am based out of Vancouver, BC. For law, I mostly do family law. For counseling, I work a lot with couples and families across Canada. I have my own counseling practice called Apollo Counseling, and I have a team of four. We are all BIPOC women and we all offer counseling sessions across Canada. So that’s where I am right now in my professional journey. I’m practicing both as a family law lawyer and also as a counselor.

Amazing. It’s such a wonderful kind of dual roles you have, and I’m sure that they compliment each other very well, and I know they will for this episode as well. So before we dive into strategies to prevent professional complaints, from your experience, what are the most common situations or scenarios that tend to get therapists in hot water, especially from a legal context?

Yeah, I don’t think many therapists realize, but their clients can essentially go report them to the relevant body or go sue them. And a lot of times the reason why clients are doing that is because the therapist notes breach confidentiality. So when the therapist notes, breach confidentiality. Now, the client is in a difficult situation because they come to you saying, Hey, I’m coming to you for therapy. I’m coming to you in a state of vulnerability. I’m coming to talk to you. However, now you have these notes that’s disclosing this information I’ve told you, and it’s released.

And when I say released, we know the limits of confidentiality, right? And one of them is court ordered subpoenas. So if your notes are court ordered, that means you need to give your notes. And you can’t really be amending your notes because a lot of times for practice, you should be locking your notes after completing them, right? So when you’re giving your notes to the court, keep in mind that a judge is now going to see it. Your client’s lawyer’s going to see it. The opposing counsel and opposing party’s going to see it. And if this goes to trial and when it does go to trial, and these notes are now in court at trial and the documents are brought up and brought to the court’s attention. Keep in mind, a lot of times in trial there is an audience, so now family, friends and whoever is sitting in that courtroom is also going to be aware of what’s in those notes.

And a lot of times clients don’t realize that we do take notes. Or they think that the notes are going to be beneficial to them, right? They don’t know what we write in our notes. They don’t know what we keep in our notes. So it gets really tricky because when the client does see the notes, one, it may not have something they want in it.

Two, they may believe that a situation or their feelings or their thoughts should have been interpreted totally differently than what we actually have them as. And three, they may have told you something that they don’t want anyone to know, and now a whole courtroom’s going to know. So when those situations arise and that client to that situation, what is the outcome? What is their solution? And a lot of times they’re going to be blaming you for that, right? Because you are not the ones who is writing the notes, in a way that protects the client’s confidentiality. So there’s going to be a lot of complaints with the regulatory body from the client. I’ve seen clients sue therapists for emotional damage.

So like I said, we don’t realize that this can happen, right? And even our classes in school and education and master’s degree, we’re not told that, Hey, we need to protect ourselves. So I think protecting ourselves is something that’s very important and will prevent professional complaints.

It’s interesting that you say protect yourself because I often hear therapists say, the reason I write such lengthy notes is because of, we’ve always heard of the, if it’s not documented, it didn’t happen. So there’s this pull between, I need to write enough to show that I’ve done my due diligence. But then it’s the other poll of writing too much, where now it’s subpoenaed and. Everyone within the court now sees these notes. So I think this goes into my next question. So what strategies can therapists take to prevent or protect themselves from such complaints? Because of course, we never can guarantee a complaint will never come.

Yeah, and I think this kind of goes hand in hand with what you just mentioned as well. We’re told to document, right? But if you look at the regulatory guidelines and we look at kind of the clinical documentation section in our kind of guidelines or handbook or whatever we have for our regulatory body.

I know in BC and a lot of other provinces in Canada, there’s nothing saying what should be in your notes. It says we should protect confidentiality. This is how we should store notes. This is how we should transfer notes. But there’s nothing actually saying what should be included in our notes.

And I think we, as therapists saying, if I add all this information, I’m protecting myself. I’m protecting the client. But I don’t think we ever think about what happens when there’s a complaint. What happens if a client tries to sue us? We don’t think about those things. To protect ourselves from these complaints.

What therapists can do is one, make their notes broad, right? I say a lot of times that we should essentially be writing the title or cover of a book, but we should never actually write down the details in that book. We want to use umbrella like categories. Something I do is I don’t really include dates. I don’t include names, I don’t include places. I keep my notes very broad in kind of umbrella terms, just to prevent those little finer details that could essentially harm the client. We don’t want to harm the client, so example that I use very frequently. And the most common example that I use is say a client comes to you and they’ve just taken a pregnancy test that has turned out to be positive. And they come to you and they’re sharing this information. Hey, I just took a pregnancy test this morning. It was positive. This is what’s happening, right? And say you document it like that and we go to court, there’s a family proceeding. And say there was a separation agreement or a clause or something saying if this party falls pregnant this claim is dismissed, or this agreement is no longer valid. And if that’s the case. Then keep in mind, the courtroom now knows, based off your notes, Hey, the client came on this session date telling me she’s pregnant. And a lot of times, I want to say, we don’t want to be the one harming our client’s case. And if you’re on the stand and you’re asked, Hey, has this client ever disclosed that they were pregnant? And you say, yes, that’s fine. But we don’t want our notes speaking for us. We want the opportunity to speak for ourselves. And I think that’s something that’s very important. And a lot of times we might not remember things from certain sessions or you may not remember things when our notes are so broad, but I don’t think people realizing, I don’t know. I don’t remember. I don’t recall. Those are okay answers if you’re on the stats, if you’re ever subpoenaed to testify.

But what I like to say is if someone is reading your notes, they should have no idea what’s happening in this client’s life apart from the issues that they are facing. So once again, trauma, depression, anxiety, terms like that. But we don’t want to know the details behind those situations. And when we prevent and avoid writing those details in our actual notes, keep in mind what is a client going to come and complain about. Because you are protecting them. And something that you can do to protect yourself also is to always tell the clients, or have it in your intake form that your notes are brief or broad. Because keep in mind, in that intake form and consent form, the client is signing that. So they’ve read it and then also emphasize in the first session, hey, these are the limits of confidentiality. This last one, court can subpoena your notes. That’s really important to keep in mind because maybe you’re not going through a legal proceeding now, but say maybe you got into a car accident in a couple of years. Say you’re going through some employment disputes. Say you’re going through a family law claim, there’s so many opportunities for a court to subpoena your notes, maybe 3, 4, 5 years down the road, right? We don’t know what’s going to happen in the next five years, and if these notes would ever have to be subpoenaed or if you ever need access to these notes.

So I always like to tell my clients that I keep my notes brief and broad, and if they’re someone that wants access to your notes to see their progress and document their progress and journey, I like to have that in writing. I send them an email saying, Hey, I know we talked about having brief and broad notes, and that’s my standard of practice. You’ve explained to me you want my notes to hold a lot of detail for your own preference. So I’m going to be doing that. And that’s just to protect yourself. So if there is something in your notes that they don’t like and they go to the regulatory body for any complaint, you have that saying, Hey, my goal when writing notes is to protect your confidentiality and to have these notes for myself to better help you in the sessions. And now you have told me that you want more details. I’ve given more details. You don’t like the details I’m putting in because now something is released to the public or released to someone you don’t know. So I’ve written you this email, you’ve signed it saying, yes, this is okay. So I think that’s something you can do to just protect yourself as well.

So you talked about this, but let’s discuss documenting carefully and thoughtfully for a second. Beyond what you’ve already shared, are there specific guidelines or processes that a therapist, could or should take when writing client-centric notes that doesn’t breach confidentiality?

Yeah, I think I’ve slightly mentioned this before, but keeping things broad. Telling the book cover, but not telling the story. That’s the goal. And I think also, for example, when I was in practicum, no one ever looked at my notes, when I was student I wanted to make sure I was remembering information from the client. I would have 10 to 20 points, lengthy points about what’s happening in the session, what was discussed in the session, because I was afraid that I was going to forget something. And over time, I didn’t realize until I was in the legal field, until I was seeing counselor’s notes, until I was seeing how they were used in the legal context, how much impact it has on a client if there is something in those notes that they don’t like from those 10 to 20 points, I now write three points per session. That’s my general rule of thumb, and I do either client center notes or therapist center notes. So when I say client center notes, I’ll say client reporting, client experience, client shared terms like that when I start my notes.

And yes, those are probably how you already start your notes, but what comes after that? Client discuss experiencing symptoms of anxiety. That’s what I leave it at, right? I don’t say what those symptoms are. I don’t give any of the details. I just say, Hey, client came to the session telling me they’re experiencing symptoms of anxiety, right?

Client shared having communication concerns in their relationship. So I know that this client now is having communication concerns in their relationship, but I don’t know the details. I don’t know what was said. I don’t know what was done. So we’re still tackling and mentioning the issues, but we’re also protecting the client by not sharing the details of those issues.

And even therapists-centred your notes, right? Therapist provided psychoeducation on, therapists shared coping strategies on, there’s so many ways we can structure our sentences and notes that we are protecting client confidentiality. And I think when we write notes, keep in mind, like I said before.

No one else should understand your notes. If someone were to read their notes, they should have no idea what’s happening in terms of details, but they’ll know, Hey, this client is focusing on anxiety and relationships, but they don’t know anything about that. Just, Hey, these are the issues that the client is focusing on.

And I think when you write notes like that, like I said before, it’s very hard for a client to be upset with you, especially when those notes are in a legal setting. And like I said, a lot of times also, clients may want those notes for their own purposes, for their own records. And if that is a case. The client will know, right? The client will see these notes.

The client will understand how you write your notes, but keep in mind also, a lot of questions I get asked is, I used to write 10 points per session. Now you’re telling me to write three. How do I make that change? How to make I make that switch? I would say, don’t wait till it’s a new client and then make that switch. Don’t wait until this client decides to take a break and you have to restart with her. Don’t do that. Just make that switch, and if anyone asks questions or if it’s a concern to someone, I think an answer that’s appropriate is, Hey, I realized I wasn’t protecting my client confidentiality.

Because that’s something that’s really important, and I’m saying this all right now, because there’s no guidelines on note taking, I think things will change as there are some bodies now regulating and things like that. But as of now, if you’re looking, there’s nothing saying how or what should be included in our notes. And if that’s the case, we need to write our notes in a way that protects not only our clients, but also us.

I love that. And there’s a few things I’d like to touch on. First of all I like that you mentioned about the regulatory bodies because of course, listeners come from a variety of different regulatory bodies and at the end of the day we still also need to kind of balance those expectations. But I do agree with you, as a rule, you don’t see a lot of regulatory bodies giving specific advice or kind of details into what needs to be included. There are some that might have a little bit more detail than others, but at the end of the day, I’ve yet to see, this is the guideline we have to follow and, this is this how it needs to be.

And the other piece that I think is really important to highlight is, the strategy for being brief. And I know we’ve talked about this offline Simren, but I use like the SOAP note strategy. And I guess that gives you four points. But at the end of the day, I’ve always used that even when I was a recreation therapist. For the most part, it keeps things pretty brief because very similar to what you’ve mentioned, there’s the client centered so the subjective side of things, then there’s the objective side of things. So the therapist kind of piece. The assessment side of it, and then the plan, like what’s the plan for next day? So I think like the additional piece that I include is like the plan, or I might include the homework, but at the end of the day, it’s you’re right. Like I don’t make it very, lengthy either. And it’s because that SOAP note strategy that I originally was taught on as a recreation therapist is still what I use today as a social worker. So far it’s worked well. But now I will say, knock on wood, my notes have never been subpoenaed or review by a regulatory body. There’s that too. But I do like that too.

I think the SOAP notes is a great kind of way to set up your notes in the sense that, yeah, it is four points, but those four points are pretty brief, right? It’s one point under each kind of heading, and I think it helps keep your notes in control and also helps keep your notes broad again. So we’re not losing track and writing 10 points again.

I think another kind of method to write notes that I’ve been told recently and that I had a few counselors tell me that they’ve been doing is having check boxes. So they have different he headings like presenting issues modality used, and they’re just checking boxes so that way they’re not writing down actual notes, right?

It’s all checkbox and there is a box at end saying additional comments that they can write. But when you have check boxes. It’s nice because you’re doing exactly what you should be doing in the sense that everything is so broad. So I think there are different ways to write your notes by keeping them broad.

Whatever you’re doing now, you can keep doing right, as long as the notes remain broad and protects the client’s confidentiality. So, like I said, there’s different templates for note taking, different ways to write notes by the end of the day, as long as you’re ensuring that. You are protecting the client’s privacy by making sure they’re broad. Any kind of template would work.

I love that. Simren, I know that various times of the year you provide workshops or Q&As about the ethical and legal considerations around clinical documentation. If any listener would like the most up-to-date information about your upcoming events how can they connect?

Yeah, so I usually send out my events on a mailing list or I post them in just Facebook groups. To join my mailing list, just send me an email at [email protected]. Every two-ish months, I basically send out email with the offerings I am offering for that month. And if you’re interested, I would love to see you there.

So to connect with Simren, check out her website apollocounselling.ca or follow her Instagram at the handle at Apollo Counselling.

Or you can just send her an email at [email protected].

Or you could simply scroll down to the show notes and click on the link.

Simren, thank you so much for joining us on the podcast today to share simple strategies to prevent professional complaints in practice.

Thanks, Kayla.

Thank you everyone for tuning into today’s episode, and I hope you join me again soon on The Designer Practice Podcast.

Until next time, bye for now.

Credits & Disclaimers

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