Updated: Feb 11, 2019
Today I'm joined by Maelisa Hall from QA Prep to talk to teach us how to make our documentation more meaningful!
As therapists we take notes for every session with a client. It can become a little difficult to manage so many notes, but Maelisa has some tips to streamline the process.
She recommends using a collaborative documentation process which will benefit both the therapist and the client. It helps us because we can get really valuable information from taking the last 5 minutes of the session to review with the client what their key take aways were. And it helps the client because they don’t secretly worry you’re writing notes that you think they are crazy. Clients felt empowered and became more involved.
Mostly importantly, if we involve the client in the process of recalling the discoveries of the session and giving them the opportunity to review in their own minds the things they’ve learned they’ll make faster progress. As you know, our memories are more strongly linked to the act of recalling an event than actually experiencing the event.
Reach out to Maelisa Hall by e-mail here: firstname.lastname@example.org
Here is a special link to her Crash Course and her new resources: https://www.qaprep.com/inspired
Tune in below or browse the edited transcript!
Leanne Peterson: I’m so excited for our conversation today, because we’re going to be talking about the stuff that most of us don’t like to think about, and that’s paperwork documentation, and really building a practice that feels good to run. I say that because there are certain aspects we all love, and I think there’s aspects that we also don’t like, so we avoid addressing, we avoid dealing with, and we really kind of push it off, and it becomes a much bigger problem than it has to be.
Today we’re going to talk about how to do our documentation, and create systems, put things in place that support us, and support the work we’re doing, instead of allowing things to keep building up and becoming a bigger pile.
So can you tell us about how you got started in this field within the field, and kind of where your passion lies?
Maelisa Hall: Thanks for having me. I’m excited to talk about this. I know a lot of people aren’t super excited about it, but I still get a lot of people who are excited to hear about these resources because we just don’t talk about it that much. It’s something we like to sweep under the rug, and try to pretend it doesn’t exist, right?
Right, exactly. Yes, as I’m talking to you, I’m just calmly trying to ignore my pile of notes sitting on my little electronic health record. So it definitely is something we tend to avoid.
I think that’s part of the reason I got into this, is that I am not naturally super organized. I’m pretty ambitious, I’m a hard worker, but I had a job at an agency really early on where I had to do a lot of assessments, and it was a ton of paperwork. It was just pages and pages just for one client, for one session.
And I learned early on that if I didn’t manage that really well, I was going to totally drown. I had colleagues who had to take a week off just to catch up on their paperwork, and I was like, “I don’t want that to be me.” So I got really good at figuring out strategies to get the work done. A big one was actually just doing a lot of paperwork with my clients in the room, and figuring out how to manage that, and how to still build rapport, and actually have a good conversation with someone while I’m taking notes. So that was a skill that I think, I think that one skill is the thing that got me through that job. And I was always able to kind of think through the paperwork a little bit differently, and wanted to look at the meaning behind it, and as a result of that, later on down the line, I ended up being in a training position, where I was teaching other therapists how to do paperwork.
Actually, with the same company but at a different location. I found that I really, really enjoyed training. It was a lot of fun, and I had the boring parts of the job where I was literally sitting there reading through files and doing reports on people’s files—although sometimes that could be kind of fun, actually, reading all the stories that everybody writes—but those were often the boring days. But I found that I really enjoyed using that information to identify what people were struggling with and then create specialized trainings for everyone and give them examples. People found it so helpful. I just kept hearing over and over, “We don’t really learn very much about this,” or, “The last person we had never gave us these examples, and this is so helpful.” The managers really appreciated having somebody who could actually collaborate with them.
So then I started talking to my friends in private practice, and they were like, “Man, I wish I had something like that,” or they would start asking me questions, and I was giving them resources. Then I realized, you know, I think maybe people in private practice need this kind of help, too. So I started QA Prep, my online business, to start providing resources for other therapists, so that they could have a way to first of all just figure out what is normal and what might be needed in documentation, but also find ways that they could make it more meaningful to the work that they’re doing. So it’s not this constant drag on this career that they otherwise enjoy.
What I love so much about your story, is that it's so relatable is that it’s not like, “I was born great at notes,” but rather, “Out of not being so great, I came up with a system that made me great at notes.” And I think that’s a great thing to highlight in your own story, and as we’re all learning to do it better, too, because it’s not some automatic gift we have. It’s something we really have to take some time to think about, and like you said, make it meaningful. Because I often struggle with that feeling of dread and forget how to bring meaning even to that part. When you think about bringing meaning to the notes, what does that mean? How do you suggest that we bring more meaning to our documentation?
I think the first thing is to remember that if you're in a private practice, you can make your own decisions. So that can be a little overwhelming at first, actually. It’s kind of like exciting that I don’t have to do all this paperwork I was doing at this agency since most of us started out in that kind of a setting. And then all of a sudden, people get this panic, like, “Well, wait. But you know, what do I put in my consent form, and how do I write my notes? How much shorter can I make it? What do I have to make a treatment plan look like?”
So you have a lot of flexibility to make it work for you, and there’s no reason that you have to write the same thing three different times, right? Which is a pet peeve of so many people, and I hate that, having to write the same thing over and over. You shouldn’t have to do that if you have a private practice because you can create your forms so that they make sense, and you can make them really efficient. So I think that’s number one, is just thinking of the practical part of it, so that you're not resenting doing certain things over and over.
Think about what are the questions you ask people. You probably have a certain clientele, maybe you have a couple of different niches, but you probably have certain questions that you ask pretty much everyone in the same intake assessment. Of course there are lots of questions we should ask people about getting that whole bio-psychosocial history. But what are the things that maybe you focus on? Or what are the things that are things that you get to talk with your clients about and that you really enjoy? What is unique to your population? Those are all things you can add into your paperwork.
Really just think of your paperwork as a reflection of the session. Whether it’s the intake session, it’s a reflection of all the information you gathered. Or if it’s a regular, ongoing session, it’s just a reflection of what happened in the room. So that it’s creating this nice story of how therapy goes.
If you could summarize it a little bit, I’m really struggling on how to do collaborative note taking, how to do notes in the session, but I also feel like, like talking about meaning, that adds a lot of meaning if it can be something that the client and I are creating together, and I am asking the questions, and they know kind of what I’m putting in, it feels a lot better to me than kind of like afterward filling in blanks. So I’m wondering how you suggest people bring this in, because I know a lot of therapists kind of have this, “Ugh!” reaction. Like, “I can’t! I can’t mess up the sessions with notes.” So I wonder how you kind of have found to work that in.
I love talking about this, because it’s like this best-kept secret to managing your paperwork. Because it helps with time, obviously. The more you’re getting done when you’re in session with people, the less you have to do afterwards, but it really does add that meaningful component.
So I know the first thing is to kind of look at the fear aspect that you said. You know, that immediate reaction a lot of therapists have, like, “Oh, I don’t know about that.” You know? So I think that’s the first thing to look at, is why is that happening? Is that because you’re not feeling confident in yourself? In the notes that you write? Would you be scared for a client to see the notes that you write? Those are really important things to consider. I do think they’re things you want to decide to overcome, because guess what? Your clients could request their records any time. Right? We all, you know, because of HIPAA, and because of just client rights laws, we all have access to our medical records, and that’s a good thing. That’s a positive thing. But you should always be writing your notes considering the fact that your clients could potentially read them.
Which, if you're like me, that always makes my heart beat a little faster, not because I’m writing anything bad, but...
You’re right, and that’s why this idea of, I think, collaborative note taking is bigger and more important than we think, because it’s nice to know, too, kind of what the client sees the focus of the session. Because I’ve had my notes requested for different things, where they might have thought the focus of the session was one thing, but I saw it as another thing, if that makes sense.
So maybe they came in for one issue, but we got into this underlying issue, and then they’re requesting notes for, you know, a lawyer needs to see them for an accident they got in, and I’m like, “Well, a lot of my notes are about your relationship with your mother.”
Right? How is that going to be helpful?
Exactly. And it’s kind of like, not that they should be dictating their whole notes, but let’s make sure we hit on all the important parts, whereas like I said, I might kind of key in on one thing, and they might’ve been seeing it as this bigger picture thing. So I like this idea of like, “You should be involved in the process, too,” since they are their notes.
And that’s such an important point, right? Because that’s really important clinical information to have. If their takeaway from that session is something totally different than what you thought it was, if you’re able to actually have that conversation at the end of the session because you're writing the notes together? I mean, that’s huge. Versus if you don’t do that and you find out two or three weeks later because it happens to come up.
The information you can get is so, so valuable, and I think the other thing that I did not expect to see—so I did a lot of research on collaborative documentation to prepare this training, because it’s in my membership program because I found it was this resource I kept bringing up over and over again. So I wanted to have a really good training and provide some direction around it.
The research really shows that one of the biggest benefits of collaborative documentation is for your clients, and that one of the things that most clients said in this research was that they secretly felt like their therapist thought they were crazy, and when they were able to see what their therapist was writing, they were like, “Oh, they’re just writing about what we talked about.”
That it really helped the clients to feel a lot closer, and to feel less of that power dynamic that can happen. A lot of clients felt really empowered, and clients tended to actually become more involved in their treatment, and reported feeling like they were more involved, and like things were more effective. It kind of goes back to that point you made, you know. It just kind of makes sense that if clients are then sharing a takeaway they had, and it surprised you because you thought it was something else, if you’re using this strategy, that’s something you’re addressing really early on, and you're catching right away. So that is going to make therapy more effective.
And there’s also research, there’s a book, I believe it’s called Make It Stick and it talks about how memory works. You know, a lot of times we’ve heard experience is what makes things stick, makes us remember things, but what the authors of this book found is that it’s not experiencing it, it’s recalling what you heard or experienced that makes it stick, and puts it to memory. So in the The Coaching Habit book, that’s where I heard about it, they talk about how it’s important to ask people you’re having a conversation with, “What did you take away from this?” Not only is it good information for us, but it’s good for the client to kind of know, too, like, “Oh yeah. I did just say that.”
Right, you just remember what you felt about it.
So like you said, I think it’s beneficial for the clients too because they’re remembering those things that in that moment were a big deal, and they can kind of commit it to their memory by doing that note process.
Exactly. And that brings up another point that is really valuable with making your documentation meaningful that I think a lot of people don’t consider until they’re in the situation, and that’s if you are kind of struggling with a client, or if you’re in that stage, maybe 3-4 months in where a client is sort of feeling like they’re not seeing a lot of progress, or—I see this a lot, especially with major depressive disorder, you know, significant depression, where 3-4 months in, maybe they’ve made some progress, but most people at that point are still depressed, so they’re kind of feeling like, “Is this really working?” and starting to feel even more hopeless. Right?
When you have good paperwork, then you can go back through your notes and you’re able to look at those things, because even you as a therapist, you can get stuck in that week-to-week schedule as well, and it can be difficult to remember, “What are the highlights of how things were going back when this person came in for their intake, and how have things changed?” Having good notes is so valuable at that time. I’ve never had it happen where I went through, looking through my notes, and wasn’t able to find something, some kind of progress my client had made, or identify some kind of a win that could help get them through that time when they were feeling doubtful about whether or not things were working.
Like you said, it can be helpful for both parties. Like you said, meaningful documentation and something that really captures it versus what we sometimes default to, which is kind of rushed notes that maybe skim the surface too much to really provide that good meat when we need it later on.
It’s actually taking the time to reflect, and you know, make it something that has some substance to it instead of just checking off boxes.
Yes. I love that. My question, at least what gets in my way, I don’t know if anyone else listening feels the same way, but it’s the logistics. It’s, you know, do I take a paper note down, and then enter it later, and that seems cumbersome because all my records are electronic health records? Do I actually pull up in my computer right there and type a few notes while they’re sitting right in front of me? How do you see it best logistically? Do you do it at the end of the session? Do you check in at the beginning and get where they’re at and then do an end wrap-up? Yeah, so logistically speaking, how do you find it works best, or is it different for each clinician?
I do think it’s different for different people. So if you use an e -HR or a computer, that’s going to be very different than if you hand write. So if you hand write, it can be a little bit easier, I think, in the beginning, to simply just have the notes in your lap, or next to you and write them that way. Most of us are using computers at this point, even if we’re not using an electronic health record, right? So you may have to, like for an intake session for example, I would always have my computer in my lap because I have a laptop. So then you just have to adjust to making sure you’re still making eye contact, communicating with people if you are writing something, so again they don’t think you’re writing about them, how crazy they are. Right? You’re just letting them know you’re just writing what they said, or that important piece of information so you don’t forget it.
I think for ongoing notes, it’s more helpful to have it kind of be like a summary, to do it at the end, and then that also helps with transitioning, so if you have a desktop and a desk, and so you don’t have a computer you can move around really easily, then you sort of transition a little, you know, 5 minutes earlier than you normally would, and say, “Hey, let’s write our note together, and kind of wrap up the session, and talk about what were your takeaways.”
That provides a nice transition to the end of things, but then also lets you, if you had to actually get up and move over to your computer, you know, maybe sit there and type, or grab your computer and bring it over to you. You have to figure out what’s going to work for you, and that’s going to depend on your office set up and what tech you have and all of that.
But I think most times, doing it at the end is sort of the natural progression for things, and it also helps with another struggle that a lot of us have, which is ending sessions on time.
It kind of prompts us to make sure we have a good 5 minutes at the end to finish something up if we’ve already told our client that we’re going to do that.
Right. I like that. And I love the way you’re talking about this, and as we wrap up this episode, I want to talk about how you’re pulling this all together, and this idea of, step one is to change how we’re seeing paperwork, and not this drudgery at the end but as this meaningful part of the work that benefits us in terms of freeing up our time a little bit, but also really benefits our clients in terms of them being able to really get the most out of their session. And like you said, just that transparency of, “Hey, we write notes, this is what I’m saying.” Kind of being up front about it and not leaving any doubt in anyone’s mind about what’s going into that note.
So I’m leaving here inspired to think about my paperwork differently, and introduce it to clients in a different way in terms of this enhances what we’re doing, and it's not here to take away from what we’re doing.
I think an important note about collaborative documentation specifically is that it does take time for clients and the therapist to get used to it. So if you try it one time, or you try it for one day with all your clients, and it doesn’t work out so well, that doesn’t mean that it was a failure and it’s not going to work. The research was pretty consistent that it takes about 6-8 weeks for both people to get used to the process, so make sure if you do it, commit to it for a time frame, and when you introduce it to your clients, you can say, “Hey, we’re going to try something out over the next 2 months,” and you can even say, “I went to this training, and most clients really like this. It might be a little awkward for us at first,” and you can admit, you know, “It’s kind of awkward for me, too, but let’s try it out for 2 months, and then we’ll reevaluate and see how it’s going.”
I love that, too! Setting that expectation right in the beginning, giving us time and them time to get used to it, because I know I am the queen of implementing something and then backing off because it’s not super comfortable yet.
So, it’s that consistency. Well, thank you so much for sharing that, and I will put in the show notes the link to QA Prep because there’s so much great information there, and there is a whole—is it a whole workshop you have on collaborative documentation?
Yes, inside the membership, there is a whole continuing education workshop on how to implement collaborative documentation as well as tons of other trainings on all kinds of different topics. If people want to use the coupon code INSPIRE, then they can get 25% off.
Thank you so much for that. So everyone head over there, and if you’re looking for a great membership program that gives you good information about documentation and other things related to therapy practice and all of that, the QA Prep is such a great resource. I’m a member, and I really have found it valuable to kind of have that accountability.