![]() ![]() Try to keep your answer to each of those questions to one sentence, then use that as the basis for what you include in your notes. What do I think will be really important to have written down for later? What seemed important to my client during our session? ![]() What stood out to me as important about our session? I recommend asking yourself some key questions while writing: However, I get it because I have a horrible memory due to my ADHD and so I have some other recommendations to improve your case and make them easier to write. ![]() My short answer is no, I do NOT recommend writing two sets of notes! That’s the opposite of simplifying things. Should I then do a summary for the legal notes?" Admit that the situation sucks, create a plan so it doesn't happen again, and move on. But let me tell you, it's still better than no note at all and you're not compromising your integrity. If you honestly can't remember what happened but you're certain your client did show up for the session, here is a brief example progress note. "What can I do if too much time has passed since the session and I don't remember anything to write as a progress note?"ĭo what you can but NEVER make up information that you don't remember. This is simply providing an explanation for why those dates are off. You're not trying to hide anything and since you should sign and date all notes on the date of entry, that won't match your session date. I do recommend that if it's been a long time (this is subjective but let's say more than a month), include something like "Late Entry" at the top of your note. But having a complete story in your client's record is always important. And there are certainly expiration dates for things like insurance claims, so that's another story. Now, if you're like me, there may be an "expiration date" for your memory. That means if the note is from last year, write it! If it's from last month, write it! There is no expiration date on writing notes. You can (and I would say, should) write any note that isn't written. "How late can I write progress notes if I'm behind?" and I hear them over and over again: 1.Writing Progress Notes Late (weeks or months after a session) These are all real questions or concerns brought up by other therapists. But I do hope to offer you some food for thought in my answers below. I am a strong believer in multiple correct answers or ways of doing things (in most circumstances). Remember that my goal is never to tell you exactly how to do something. How do we keep non-clinical case notes for our memory sake? It appears that process notes can also be subpoenaed. What are psychotherapy notes based on HIPAA? ![]() How to document in a problem focused way to satisfy insurance, disability, etc when the session is strength based and optimistic. Since I've started taking insurance, I've become stressed with note taking. I'm finding myself writing 1-2 page progress notes.
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