Even though writing progress notes is a part of daily work for therapists, it is only makes up a tiny part of the education required for the job. Without trying to replace the record keeping training that various professional orders offer, this article will share some tips to help you write progress notes that are reflective of the clinical process.
2 Reasons to Master your Record Keeping
(Specifically writing clinical notes!)
Progress notes are a legal requirement! The various laws surrounding therapists’ practice require that a file be kept for each person to whom professional services are rendered. For therapists practicing in Quebec, this record keeping must be done in compliance with the Act respecting Access to documents held by public bodies and the Protection of personal information or the Act respecting the protection of personal information in the private sector, depending on the work context.
The file has different functions for the person receiving the services and the person providing them. It:
- Allows the rights of the person being cared for to be met in reference to the two laws mentioned in point 1, specifically, access to information concerning them and the possibility to request rectification of certain information.
- Ensures the quality of follow-ups by reflecting continuity, quality, and coherence of services provided.
- Allows the therapist to be protected by providing records of services provided, professional acts performed, and the associated clinical reflection.
- Allows the quality of services to be evaluated, specifically through professional inspections.
- Allows various legal requirements to be met in the case of a disciplinary investigation, for example.
It is important to remember that the file belongs to the person receiving the services and it is a professional responsibility to ensure that anything written is intelligible to that person, and any other person who may have access (therapists, multi-disciplinary team, court, any other authorized person).
Anything that is not included in the file is considered to not have been done, so it is important to ensure that all professional acts performed have been recorded, along with documentation of the clinical process. Progress notes cannot be in the form of a transcription or an account of the session. To be considered as clinical, the notes must make it possible to determine what was done, with whom, in collaboration with whom, why, whether or not it worked, where the therapist is in the intervention, etc. The therapist must always keep their accountability in mind.
Important : deadlines for finishing notes are not put in place to create stress for the therapist, but rather to protect them; The more time passes, the less reliable and credible the note is considered to be.
How to write progress notes efficiently?
There are different templates available to help with note writing that, in general, include the same information but with varying structure and organization. We have selected three to show you today that could be used to create a template for your own note writing if you wish. These models for writing progress notes help with being more concise and relevant with the information included in the file.
In your Psylio account, we provide you with multiple templates for progress notes and you can also upload others to suit different models of writing using our tool Progress Note Templates.
How to ensure progress note quality?
The Order of Social Workers, Family, and Marriage Therapists of Quebec offer a continuing education course called “File Writing: Standards and Practice Guidelines for Social Workers and Family and Marriage Therapists”, which outlines six criteria for evaluating the quality of a progress note.
- Is it pertinent?
- Is it organized?
- Is it concise?
- Is the information objective and accurate?
- Is it complete?
- Is it clear, legible, and free of spelling errors?
More information on each of these criteria can be found in the Progress Note Writing Guide tool we created for you which provides various writing templates and concrete information to facilitate their use.
In conclusion, although writing progress notes can take a lot of time, it is undeniably an integral part of the clinical process that allows the clients’ rights to be respected, professional obligations met, and protects the therapist in case of legal or disciplinary proceedings. A record-keeping platform like Psylio allows you to simplify your record-keeping with templates and have more time to spend providing services to clients!
Product specialist, Social worker, B.T.S.
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