Show Notes

Kayla: Welcome back to the Designer Practice Podcast. I’m your host Kayla Das.

Do you struggle with documentation anxiety?

In today’s episode, we have a fan favorite returning guest on the podcast. Beth Rontal, Licensed Clinical Social Worker, Case Note Documentation Specialist and owner of Documentation Wizard. Beth is going to answer the most commonly asked questions about case note documentation so that you gain clarity and control over your case note writing.

Hi Beth. Welcome back to the Designer Practice Podcast. I’m so glad you’re here again. It’s been almost a year since we’ve last had an episode together, which was really early in the podcast start-up, episode number seven. And now this is episode 50. So having you back on the show is definitely overdue.

Beth: Thank you so much, Kayla, and congratulations to you for almost a whole year of podcasting.

Kayla: Thank you. It’s been such a wonderful experience, and I couldn’t do it without the listeners, for sure.

Beth: For sure.

Introduction

Kayla: So, before we dive in today, though, please introduce yourself for any listener who might have not had a chance to listen to our last episode or may not know who you are.

Beth: Well, I will tell you that I got into being the Documentation Wizard, kicking and screaming. It was not what I originally planned. I thought that I would be a trauma therapist. That was what I wanted. And I didn’t think that documentation had anything to do with providing good therapy, particularly trauma therapy.

And I didn’t learn documentation on the job. I certainly didn’t learn it in school. And I was a dual diagnosis counselor working in residential settings. I did outreach therapy, working in people’s homes. I’ve worked at an agency and then a clinic and hospitals that have experience in EAP and geriatrics and major mental illness. And in none of those did I learn clinical documentation.

Until, at the clinic job, I was promoted to supervisor and part of my job as supervisor was to help create the clinic’s first digital documentation system and teach it to my supervisees. Now, I’ve had over 50 supervisees from interns to clinicians during the 11 years I supervised there. And because I had to teach it, I had to learn it and I struggled. And it’s the struggle that actually allowed me to notice that there’s a formula for creating the golden thread.

The golden thread is what ties. our documentation and informs our documentation from intake to discharge. And I figured out the formula and I figured out how to teach it. So, I can help therapists turn their clinical skill and intuition into a formulaic form of documentation, which sounds awful because why should documentation be a formula, but Therapy is not a formula. Let’s simplify something. Let’s make it easy to do. And that’s what I do.

Kayla: Well, I know that your services is very much needed in the therapy world because even though I know when I actually did my first degree, which was actually in recreational therapy, it wasn’t even in social work at that point. I did a course in documentation, but I did not do any type of course in my bachelor or my master of social work. Well, I should correct myself there, we did psychosocial assessments, but we didn’t talk about what would a documentation look like. And of course, we have our practicums that taught us a little bit of that too. But I have noticed that most of us come out of our programs and we really don’t know what’s expected when it comes to documentation. So definitely, I know this episode is important because we’re going to be talking about some of these things, right?

Defining Documentation Anxiety

So, first of all, when it comes to documentation anxiety, what is it and what contributes or heightens this anxiety for practitioners?

Beth: So, documentation anxiety shows up in this kind of behavior. I’d rather clean the toilet than do my documentation, than write my notes. Postpone it. Avoid it, which winds up making you feel like you’re not a good therapist. You don’t know how much or how little to write. And that lack of clarity is extremely anxiety provoking.

Now we got the lack of clarity, because we weren’t taught in graduate school and the reasons we weren’t taught in graduate school is because our teachers assumed we would learn how to do documentation on the job. And that every clinic we went to serve a different population, and therefore had different documentation requirements.

Well, there is some truth in that, different clinics do have different populations that do have some requirements that may be specific to them. But there is a standard for documentation that’s across the board, and that needs to be what’s taught. And unfortunately, this lack of clarity about it gets passed down from generations of teachers because they don’t know, because they weren’t taught, because they were told they would learn it on the job, and they didn’t.

The other thing that is difficult is we get confusing messages. Some people say, keep your notes really vague, and they say less is more. And then if it’s not documented, it didn’t happen, and that is a phrase that terrifies therapists and makes them want to write a novel for every note that they write. So, lack of information and mixed messages is a bad combination.

Kayla: Yeah, it sounds like they’re the main contributors and I would agree from even my own experience.

Managing Documentation Anxiety

So, are there ways to manage documentation anxiety if a therapist is experiencing this within their own practice?

Beth: Well, I think that the way to manage it is to learn the requirements and take a training. Don’t rely on other people who have had the same lack of experience you’ve had. Because then this misinformation keeps getting passed down and repeated. And, learn the requirements.

Have templates that cue you to include everything you need. I have seen templates that have these big boxes on it that say clinical content. And we’re supposed to write the clinical content in that box. Well, to a therapist, isn’t everything clinical content? It is to me, right? So what goes there? What I recommend is having a template that just separates and details everything that goes in that clinical content box so that you don’t have to remember. So that it’s clear and you’re not missing anything.

Kayla: That makes complete sense and would actually help with the overwhelm too because often we’re looking at a blank page or we’re writing on a blank page and as a result we’re like, what do I write? Whereas if you have that template that you can go to over and over again, its half written. It’s really just plug and playing the information that’s really important for you to put in there.

Beth: That’s absolutely right. When you’ve got a good template, you can write a note in 3 to 10 minutes. 3 minutes, if it’s really simple. 10 minutes, if you’ve really got to think about it. 5 minutes is pretty much 5, 6 minutes is pretty standard. And that’s really great for a lot of people who take 20, 30 minutes to write a note, which is completely unsustainable.

Kayla: So, now let’s get into the most commonly asked questions. And now you and I both put our heads together here to determine which ones we tend to hear most frequently. So, we’re just going to go through each individual question and I’m going to say them as if someone was asking you that question.

FAQ #1: Is there a specific timeframe to have case notes written by?

So, when it comes to writing case notes or progress notes, is there a specific time frame that a therapist should have these written by?

Beth: That is the most commonly asked question. And people give lots of different answers for that. And I have a Facebook group and that question comes up about once every two months. And people throw out answers and they often contradict each other. And that’s because there is no one right answer, unless your state has a guideline or a law, or the particular insurance company has a law. What we’ll find in our Code of Ethics, what we will find in most of the instruction manuals for insurance companies, now insurance companies, I’m talking about the U.S., of course, is within a reasonable time. That is a quote. Your notes are due within a reasonable time.

So, what’s reasonable? So, people make up what’s reasonable. Some people, some agencies say 24 hours. Other agencies say 72 hours. Medicare in the U. S. wants them done in 24 hours, but they’re actually pretty lenient. How do I know this? Because at the agency that I worked at, which is in the U. S., we were required to turn in our notes on Monday afternoon, because billing went in a few hours later. So, our notes didn’t have to be written for almost a week, and I guarantee you that our clinicians did not write them the day they got– they did outreach, so they were people’s homes. They did not come home and write their notes. So, they could wait 5 days before they wrote their notes. And the clinic passed the audits and the date stamp was not 24 or 72 hours.

So, within a reasonable time makes you wonder what’s a late note. So, a late note in my book, this is my opinion now is not a week. A late note, two weeks, you’re beginning to get there. A month is a late note. And not only that, if you haven’t written notes for a month, you could be a hundred notes behind. So, if you’re writing a late note, just indicate that on your note. Late entry with the date. Well, the date will be there if you’re using a digital system.

Kayla: I like that you connected it back that different states or different provinces might have their own different regulations. But even from what I’ve seen, that reasonable timeframe is typically always used. And again, like you said, what is reasonable, but I think it’s really important to acknowledge even the purpose of the notes, right?

Something that I find when I write notes, and this is not talking about the legal or ethical requirements, but if I’m writing a note really late. The next time I have an appointment with a client, I can’t even remember what I talked to them about. So, for me to write a note that late can actually impact my ability to be able to recall and remember and be able to move forward with the next step into whatever that treatment plan has said.

Beth: Well, you’re absolutely right. The later you write a note, even if you have what I call memory notes, the notes that we write to cue our memories from session to session. Even if we have a memory note to help us, it still takes at least twice as long to write a note because we have to go back and recreate the entire session for ourselves.

Kayla: I agree a hundred percent.

FAQ #2: Do I need to document phone calls, consultations, no shows or cancellations?

So, the next question is, do I need to document phone calls, consultations, no shows, or cancellations?

Beth: Oh yeah, oh yeah. If you’ve got a no show or a late cancellation, if you don’t document it, you don’t have any proof that it was a no show or a late cancellation. And, it also means, at least in the U.S., that if you have no proof that there was a session and it was canceled inappropriately, at least for the therapist, it was canceled inappropriately, then you can’t charge that client for the missed session.

And having a record of phone calls and consultations helps to protect you and your practice, because what happens if you’ve got a suicidal client, and that person either attempts or completes a suicide, and the family, rightly so, wants to talk to the therapist and say, “What happened? Didn’t you know?” And you didn’t get any consultation or you got consultation, but you didn’t document it. That’s where that saying is appropriate. If it isn’t documented, it didn’t happen. So, by documenting those consultations, those phone calls, those video consults that we have helps to protect us as well as helps us with treatment planning and working with the client.

Kayla: Good point.

FAQ #3: Does a treatment plan need to be written after the first session?

Does a treatment plan need to be written after the first session or can it be created any time thereafter?

Beth: That is the second most commonly asked question I get. So, again, the answer is within a timely manner. So, what is timely? My belief, as a therapist, is it takes longer than one session to get enough information to write a useful treatment plan. And if we’re going to write a treatment plan, it might as well be useful. Right? In the first session, we’re reviewing our practice policies and having people sign releases of information for their prescriber, whomever might be appropriate. And we’re beginning to take a history of the presenting problem. But that’s just the beginning.

So, I think it takes two to three sessions to get enough information to write a useful treatment plan. And the clinics that say we want a treatment plan right after the first session. And the EHRs that insist that you write a treatment plan along with your session note, your first date of service, I think are simply trying to ensure that it gets done. And they know that therapists don’t want to do it. So, they kind of turn the screws really tight.

But particularly if you’re in private practice, take two to three sessions. And if you, at least in the U.S., because I’m not really sure how billing works in Canada. But in the U.S., if you want to submit to your insurance company and you don’t have a definitive diagnosis, just put adjustment disorder with Anxiety or Depression or both, and you can change it once you find out.

Kayla: That’s a good point. And just for a little bit of clarification for even listeners listening, that in Canada, our insurance billing is very different. And actually, a patient or a client can actually submit their receipt to insurance company and get reimbursed according to their plan. Now there is such thing as direct billing. But it does not sound to be near as complicated as the U. S. And clients can even submit their own receipts after the fact to get reimbursed. And it’s not a requirement to provide notes or anything like that to the insurance company with respect to that. So, it sounds like it’s very different.

Beth: It’s very, very different. We write receipts for clients to submit to their own insurance companies when it’s appropriate to do that. But what you’re describing is 180 degrees different.

Kayla: I would agree.

FAQ #4: What should be included in a treatment plan?

Going back to treatment plans though, what should be included in a treatment plan?

Beth: That is the third most common question. So, I’m going to run through the requirements, but here’s what you’ve got to know about the requirements. You can hear what they are, but you still may not really get how to fulfill them. And that doesn’t mean that you’re not a good therapist. It just means you don’t have the practice yet, that you don’t understand how it all fits together. So, we need to have, of course, the diagnosis. And with the diagnosis comes the symptoms. But the symptoms aren’t really enough because the symptoms don’t tell us the behaviors that the client is engaging in.

Presenting Problem

What does the client do or not do that shows that they’re depressed, for example. So, we need to write our problem in a way that represents or demonstrates the behaviors. So, for instance, major depressive disorder as evidenced by daily crying for no reason. Now that is a symptom, but that’s also a behavior. So, you want to ask the client. Well, when you feel hopeless, what are you able to do? What can you not do? What is the hopelessness make you do or not do? So, you’re getting a real picture of your specific person, your client sitting in front of you.

Goals

And when you get a specific picture, then you can actually have goals. So, goals come after the problem. Now the problem with most digital documentation systems is they go right from the diagnosis to the goals. And that’s not helpful because you don’t really know what the problem is. So, after you have clearly articulated the problem, we go to the goals. And the goals are the solution to the problem. If the client cries every day for no reason, the client will not cry every day for no reason. Or the client will cry two days out of the week as opposed to daily. Or eliminate crying for no reason.

Objectives

Once we have goals, we go to the objectives. Objectives are what the client does to reach the goals. So, they’re actions, right? And you’re always write them in action-oriented language. Let’s go back to the problem. Let’s take sleep as the problem. If the client has a problem with sleep, let’s find out what that problem really is. Are they sleeping all day and awake at night? Are they having nightmares? Are they having trouble falling asleep? Are they having trouble staying asleep? Are they waking up multiple times a night with the difficulty of going back to sleep? That’s specific. And if they are, how often is it happening? Now, it can be difficult to get that information from a client for sure, but that’s what we’re going for. We’re going for as many specifics as we can.

And some therapists have a really hard time with this because they don’t do real behavioral work, but even cognitive distortions is a behavior, it’s a thinking behavior. So that can be documented. So, if we have the client has trouble falling asleep five nights out of seven, wakes up late and has trouble getting to work on time, is late for work three out of five days a week. Now we have a problem, right? It’s clear. Now we can create a goal. So, the goal would be it can be written in the negative using passive language. Client will not have a problem falling asleep five out of seven nights a week. Client will be able to get up on time and will get to work on time. Once we know the goals, we go to the objectives, which is what the client does. So, what is the client going to do for a sleep problem? The client is going to practice sleep hygiene techniques.

I’ve already identified some of the things that the client does that is making it difficult for them to get to sleep to get up in the morning. It could be that the client hates their job. So, we might want to identify the thoughts that the client is having when they go to sleep. We might want to create a routine, turn off all electronics two hours before. Do you drink coffee? When do you stop drinking coffee? Well stop drinking coffee at three in the afternoon rather than seven at night. But generally, engage in sleep hygiene is good because it’s general and you’ve got a lot to choose from.

Interventions

So, once you have the objectives, then you have the interventions. And the interventions are what the therapist does to help the client reach the goals. So, if the client is going to engage in sleep hygiene, then the therapist is going to teach sleep hygiene. It’s so simple.

Progress

And then we have progress. And the problem is written in behavioral language and progress is written in behavioral language. So perhaps the progress is client falls asleep easily four nights out of five gets up every day on time and is no longer late for work. That’s pretty great progress, and it’s clear. And everybody likes progress, right? In the U.S., the insurance companies love it, the therapist loves it, and the client loves it.

So, when we have something specific that we can look at and look back on then the client can feel good about what they’re doing. And I don’t know about you, but I’ve been in therapy with somebody for six months, a year, and they say, nothing’s changing. And then we go back to the treatment plan, and we take a look, and they go, “Oh, okay, it’s not changing all at once.”

Kayla: They see the progress as time goes on.

Date the Range of Treatment Plan

Beth: Yes, they do. So, after progress, you want to be able to date the range of the treatment plan. Are you doing a plan for 3 months, 6 months or a year? So if you’re doing a treatment plan for a year, then let’s say you started treatment on January 2nd, 2022, the treatment plan would go to January 2nd, 2023. That would be how you date your treatment plan. I don’t end it a day early because it’s just too confusing and everybody’s going to understand what you’re doing. So, I say make it simple.

Modalities and Frequency of Treatment

We also need to include the modalities and the frequency of treatment. By modality, I don’t mean the therapeutic technique. I mean, are you doing individual? Are you doing family or couples? Are you running a group? Are you doing case consults? And how often are you doing them? Now, individual therapy is usually either weekly or bi weekly or every other week. Case consults might be PRN, as needed.

Duration of Treatment

And then finally, we need the duration of treatment. And this throws therapists into a tizzy, because how long do I know therapy’s going to last? If you do short term goal oriented or outcome-oriented treatment, you know it’s going to be three to six months, maybe nine months. But if you’re doing trauma treatment, it could be years. You just have to show that you’re not being paid to be a best friend, that you have goals, that you do expect it to end at some point. And you can say two years, one to two years, and you write a treatment plan at the end of your first year, and you say, “Well, client made XYZ progress, but it’s still going to be another one to two years,” then you document another one to two years, but it’s clear in your treatment plan review what the progress is and why it’s going to be another one to two years. We just can’t be paid best friends. Not that I think that paid best friends are a bad thing. I actually think they’re a very good thing, but it can’t be us.

Kayla: That’s fabulous. And the way you brought us through the treatment plan and what needs to include is so helpful because it really can help us visualize. Going back to the template you mentioned earlier, you almost gave us the beginning of a template. Now as therapists, it’s what goes into each subsection of that template. So, we can make it even more simplified, but you already gave us a little bit of that. So, I love that.

Beth: Thank you. I want you to know that as I was doing that in my head, I was visualizing my template. So that I could actually walk myself through the steps.

Kayla: Yeah. So, it shows you how good having a template is because you can visualize it even when it’s not always in front of you. I love it.

FAQ #5: How long should I wait to discharge a client?

So, the next question, and I actually hear this one a lot from therapists. How long should I wait until I discharge a client?

Beth: So, there is no one answer. I say it depends on your comfort with risk. And I, as a young therapist used to hope that a client who had been no showing me repeatedly would show up and I would be able to make the difference and she would be consistent with therapy and get better. And I kept her on my records for like three, four months. Because I asked my supervisor, how long? When do I discharge her? Whenever you want, he said, which was not all that helpful. But I’m sure other people experience the same kind of answer.

So, I’m going to give you some parameters. You want to consider how much responsibility you want for a person you don’t see. If you don’t see that person and you don’t discharge them, you are still responsible for their care. What happens if they walk out of a bar, pass out, get taken to an emergency department, the social worker at the emergency department says, “Do you have a therapist?” And they say, “Oh, yeah, I have a therapist. It’s Beth Rontal.” And the social worker recommends that he comes back and social worker calls me and says, “We have your client here.” And I’m thinking, “I haven’t seen this guy in six months. I don’t know anything about him now.” And “Well, he’s going to come back. I’ve convinced him he needs to see you.” You may be full and you also may not want to see him. And that is your prerogative. That is a therapist’s prerogative, but you’re on the hook. What happens if somebody completed a suicide who you haven’t seen in three months? You’re on the hook. I’m not talking lightly about any of these circumstances. They’re very real and they’re horrible. But they don’t have to have a lasting impact on one’s ability to practice. In other words, you won’t get hauled off to the ethics board because of it.

So, I recommend having a policy in your practice policies, and my policy is that if you no show. And I don’t hear from you within a week to reschedule, then I will discharge you. And if the person is no showed, I will email, text, call, and if I don’t get a response, I will say, remember the policy. And I do go over all of my practice policies during that first session, which is why I’m not writing a treatment plan after the first session. And if somebody misses like three sessions in two months. They’re not heavily invested in therapy. If they travel a lot for work and their travel can be last minute, then that’s something that you work out with your client ahead of time. You don’t have to be draconian about your policies, but you have to have a policy and then you need to stick with it or have really good reasons why you haven’t. This protects us and therapists are really well known for doing everything they can to take care of the client, but not themselves.

Kayla: I love that you brought up policies because even in some standards of practices within therapy licensing boards, they’ll even have specific section in their standards of practice, sometimes they might actually differentiate what policies need to be included. But sometimes they say, having clear policies, even as an overarching standard. But if we don’t have these policies from both the ethical standpoint. As well as our own practical, like, how do we run our business day to day, because that’s a very business-oriented thing to have so that we know what the standard is that we are going to do in our own business so that we keep everything aligned.

Beth: Absolutely. And having policies and reviewing them with the client is part of therapy. It’s demonstrating good boundaries. It’s demonstrating clarity in what’s expected and a lot of folks have not had that in their lives. They haven’t had it modeled and they don’t know how to do it and that gets them into trouble. So just going through our policies with clarity, is therapeutic.

Kayla: So, we have two more questions.

FAQ #6: If I discuss a specific case in a case consultation with my clinical supervisor, should I document the interaction in the client’s chart?

So, if I discuss a specific case in a case consultation with my clinical supervisor, should I document the interaction and case consultation in the client’s chart?

Beth: Absolutely. And actually, we touched upon this earlier. If you get consultation, definitely write up a case consult note because it could protect you in case of any kind of legal issues or if your client decides that they’re upset with you for some reason and files a complaint with the board, then it becomes a he said, she said, or she said, she said, or they said, they said. And if you don’t have it documented that you got consultation on this issue, you have no proof. So, what happens when there’s an ethics complaint is that the board immediately looks at your notes. So, any complaint becomes about your notes right away.

FAQ #7: Is it common for clinicians to fall behind in their case notes?

Kayla: So, is it common for clinicians to fall behind in their case notes? And from your experience, how far do some therapists fall behind?

Beth: Oh, well, even the Documentation Wizard falls behind in her case notes. I am looking at my weeks’ worth right now. Because it’s been quite a wild week, but I will actually get them all done today. It is not uncommon to fall a week behind. It’s not uncommon to fall a month behind. But it’s not good because most therapists are carrying 20, 25 clients or more. And, that’s a hundred notes and some therapists are a year behind. It’s not uncommon two years behind. I’ve heard it all.

Make a plan to figure out how many notes you’re behind. If you know that it usually takes you five minutes to write a note, double the amount of time, because you have to go back in history and come up with the number of hours you think it’s going to take. Write it into your schedule. Do it with a colleague or a friend, play music, give yourself an M and M after each note, do something that helps you get it done. For me, it’s listening to music because when I’m writing notes, I tend to feel like, “Oh man, I haven’t had a break all day.” And so I’m like craving company and the music winds up being my company. And I get my notes done.

Kayla: That’s a fabulous strategy. I’d actually like to share my strategy. So, if I fall behind, I’m competitive. So, what I do is I set a timer for myself. I don’t know if anyone has ever heard of the Pomodoro method. I set a timer for myself on my phone and I make sure that I have the most obnoxious ringtone that possibly could exist on there and I try to race the clock because I really do not want to hear that ringtone go off. And because I’m competitive in nature I always, well, I don’t say always, majority of the time get it completed before the timer goes off just because I don’t want to hear it.

Beth: That is a fabulous strategy and it’s actually a strategy that I have on my 25 tips to getting notes done.

Beth’s Free 25 Tips to Getting Notes Done Resource

Kayla: So that actually brings us into, you have a free resource that you would like to provide listeners to support them with their case note documentation. Can you tell us a little bit about this resource and how it can help therapists?

Beth: Yeah, sure. It’s 25 tips. So, it’s not just the tips, but it’s how to implement the tips and why to implement them. And people find them incredibly helpful. Just hearing my playing music and my reason for playing music might be really helpful for someone. Hearing your beat-the-clock technique. It’s terrific. It’s really good for people who have ADD because they do well under time deadlines and do well under pressure. So, I have 25 of these tips. And I believe the last tip is forgive yourself and be kind to yourself.

Kayla: I think that’s a good reminder for all of us.

So to sign up for Beth’s freebie, 25 Tips to Getting Notes Done, head to kayladas.com/bethrontalfreebie.

That’s kayladas.com/bethrontalfreebie

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

Thank you, Beth, for joining us again today on the show and answering these frequently asked questions. I know I’ve certainly learned a lot from today and actually feel a little validated in some of the things that you’ve shared. It really normalizes some of, I think what all of us therapists go through and I found that this was really helpful.

Beth: I am really glad. My goal is to have therapists be empowered.

Kayla: I think you did that today.

Beth: Thanks. It’s been a pleasure.

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.

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