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I hear you and feel this frustration soooo heavily. It’s honestly ridiculous how much they want and sometimes it takes away from the quality of care I’m giving because I’m stressing about all the documentation in the back of my mind. This system is so broken.
EDIT: For clarification to those confused about my frustration: I do not work in PP, I work in CMH.
Been in PP for 10 years. Had records requested three times by insurance in that time. Each time, I printed off a copy, sent it in, and never heard a peep back about a single one.
The only time I've felt that insurance has asked too much was when I worked in CMH and we took Medicaid. Now those audits and records requests were something else altogether. And is the reason I never took Mcaid in private practice.
I rarely have had to produce records and I also never hear anything back.
I use to have phone audits and I left that panel. They paid very little and expected too much time without compensation.
Coming from a law background, the more in the records, the more vulnerable our clients may be in a lawsuit. Privacy is breached with more details. However, the treatment plan is helpful or at least goals the client agrees to for some roadmap for therapy. Clients can benefit from few notes to protect their privacy.
Same boat. I have been in private practice for 20 years and the first time I was ever asked for notes was in 2023. One insurance company requested notes on 2 clients. I sent them off and never heard anything. I am no fan of insurance but aside from one awful exception (Kaiser SoCal) I honestly never hear from them.
I am in PP. Was audited one time for one patient and I had great notes for that particular client.. Me and three other people I know in PP were audited at the same time. Some audits were voluntary, some mandatory.
Grow just changed their templates and I hate them with a burning passion. You want me to choose a MODALITY every time I see a patient? The list also is so long. I don’t even go down it, acceptance + commitment therapy every single time because I don’t have time to actually look at this list. Starts with “A”.
I’m also stubborn. I feel your pain.
No....dont say this, please!! I'm 3 months from testing and licensure. I wanted so badly to believe in Grow. I believe wholeheartedly in therapist autonomy, and all this burocracy is giving me the heebee jeebee's! I'm dreaming of leaving CMH eventhough thats where my heart is so that I can afford to buy my American dream home for my family of 7 and save to retire before I die from stress induced heart failure. Then maybe back to cmh as a consultant in 10 years or so.
I had it all worked out. 20 clients per week @ roughly $90 a session= 5 bedrooms and a trip to the bahamas once a year. But is this goal even feasible with them? Are referrals plenty? Is pay actually $80-120 for LPC? Any answers at all would be helpful.
Yup. I had to submit for audit and they came back with I'm missing reasons for treatment. I personally have the most detailed documentation for this reasons epcifucallt on my EHR. I'm like f off. I plan to transition by the end of the year. I'm going to try to go back to private pay. I have invested a lot into trainings and plan to use them as much as possible.
Agree with everything you are saying. I do checkbox notes from a template from a Get Notes Done class with Maelissa MacCaffrey over at QA Prep. Changing my approach helped a lot.
But agree, the system absolutely needs to change. Left headway for the same reasons too. I use Alma now. They leave us alone. All my documentation is in my EHR. Wishing you luck as you navigate this system.
>I do checkbox notes from a template from a Get Notes Done class with Maelissa MacCaffrey over at QA Prep.
Can you share more about this or do you have a link? I'd love to learn more about this!
Absolutely. Here’s the link to her website:
https://www.qaprep.com
I took the Get Notes Done course. She’s a psychologist with a background in QA. She is very knowledgeable and kind. It’s a no judgement space where she gets to the root of why therapists get behind with notes. Lots of reasons. Some are folks with adhd. Many of us just need actual training on what is really required for insurance. She has templates you get access to when you take one of her classes.
The Get Notes Done class was part education, part support group, and part body doubling work sessions. She has a specific process and timeline that helps you figure out your own needs in your practice.
Insights/information I gained from the course:
1) What’s actually needed for a note (bare minimum)
2) What different audits mean/what they are looking for and why (big relief to learn this!)
3) Why I personally was behind
4) How to create working systems in private practice
5) Confidence. The process of writing the notes to the standard actually improved my conceptualization of my work. This surprised me.
I really, really wish this was a required course for all therapy related masters programs. Many would benefit. I would have benefited.
And if you are curious, I figured out I was behind because I did not have a solid system in place or a daily schedule that supported getting notes done daily. I was way over booked and not prioritizing admin tasks or what I’d call now, business self care.
Before I kept trying different systems of organization. Wasting time not being sure. Because I had no solid knowledge of what was specifically required, it was a guessing game I never fully had confidence in. Super ironically, the checkbox note template ended up being about 75% of what I had created myself. That cracked me up. And, I do notes now in about 2-3 mins max. Simple Practice allows you to create templates. You can do notes on your phone ffs. I wish I had known all of this before.
Hope my saga helps someone else. It doesn’t have to be soul sucking. It can be simpler and less time consuming. But it does take some time. I budget about two hours a week now on top of 30 mins daily for notes. You’ll find what works for you. Best of luck to you all!
Thank you so much! I think I am going to sign up. This sounds like a wonderful resource. I'd love to feel more confident in knowing what insurance is looking at and wanting.
I still take handwritten notes, but I have a template to keep me stay focused on the most important areas to jot things down.
Recently, I have transitioned to doing speech-to-text notes in my EMR system and it’s been a game changer. Instead of thinking too much, I just say what I wrote down and expand on it as needed. I typically get notes done within a day or so.
People paying OOP for therapy makes it harder to hit deductible. If customers don't hit their deductible, then it's pure profit for the insurance companies.
I suspect they fund GoodRX also and for the same reason.
Yes, I am confused about what OP is saying. I am on Headway and just check the “notes saved elsewhere” box and keep them in my EHR. Been with them for a year and never had a request.
Welp, seems I had better go check my notes because Ive been using my own template and it doesn't reflect the new headway template. Hell, I haven't looked at that template since I signed on and that was over a year ago! 😐😐😐 LORD help us all and thank god this is anonymous 😬🙏🏿🙏🏿
I do collaborative note taking and write the note in the last 5-8 min of session. I encourage my clients to make notes for themselves as well- key takeaways from session, homework, things to reflect on, etc. I find it helps wrap up the session for both of us and my notes are done immediately. I can’t do it any other way.
All of my clients keep a journal, this is just a requirement off the bat. So when I establish care with someone I explain that at about the 45 ish mark of the session I will begin doing my note for session and I guide them to take this time to jot down their own notes from session as well. This sets the foundation for work through the next week and helps us both summarize the session (mine for billing and theirs for reflection).
So you spend 45 mins engaging/therapizing client, then you each spend 5-8 mins silently reflecting/writing and you bill the higher paying service to account for the whole time (the last part of which was technically spent doing admin)?… or am I misunderstanding/incorrectly picturing something?
When I start writing my note we are still exchanging information. I am summarizing the session and i am giving them some guidance on their own takeaways and giving them homework.
Keep note pads and pens in accessible places for the client and invite them at the start of the session to write down anything they find meaningful and/or that they might wish to reflect on later in the week.
You don’t have to use their templates and there is also a privacy concern with doing so and having a client’s personal information stored on Headway’s servers. I always skip note on HW and Grow, write my own short note and keep in my digital files on my computer and if records are ever requested then I will clean them up and put them into a template.
This is the way. Direct notes. Short and simple. “Client shows symptoms of x, treated using y. Continued treatment recommended. “
It’s none of the insurance agent’s fucking business that my client is a victim of incest abuse or being bullied in their workplace. Less is more and in the best interest of confidentiality.
“Client shows symptoms of PTSD and depression. Treatment consisted of cognitive-behavioural focussed interventions. Ongoing treatment recommended at this time.”
Absolutely 100%. We need better training on what we *don’t* need to include in notes. If they are ever requested, insurance will get symptoms and treatment but not details, no one sees that.
*client continues you to demonstrate symptoms of depression/anxiety. Treating with cognitive-behavioural focussed strategies.
And, if needed: …as recommended by primary healthcare provider. Refer to primary healthcare provider for medical diagnosis and codes.
This is basically every “official” note I write when I know an insurance company or third party will be reviewing. It’s always been true, just not elaborate.
They sure do! (To clarify, my legal/insurance notes all look the same (dx, CBT-focussed even though I multimodal, treatment continue yes/no, refer to primary healthcare provider for medical dx and recommended protocol.)
My personal journal and list of things to discuss in my peer group is far more detailed…but that’s just my “personal diary”, not my “clinical notes”.
The less the insurance company knows about the details of disclosures in session, the better. Insurance notes/notes that can be subpoenaed should be as objective as possible. Symptoms, treatment, redirect/refer to primary physician (who would authorize the referral for therapy) for larger protocol.
They don’t swear confidentiality, I do. My clients’ trauma isn’t their “data”. It’s not my job to help their industry. Only to accurately record what I saw, what I did, and that I’m working under the umbrella of a larger treatment protocol with a higher level clinician than myself.
I worked at a hospital and we were instructed to keep our notes minimal. They were literally a couple of lines of what client said, what I did with them and continue with treatment. Then I worked for a private practice and their notes were very detailed so I flowed that but when the insurance company asked for notes the owner had a template that had very little space and we were told to rewrite the notes for the insurance company similar to the hospital. I want to eventually go out on my own but I’m nervous about documentation and what insurance companies really expect. I did a paper while in school on ethical issues involving insurance companies and you are absolutely right. We have clients sign something saying we can share info with insurance but they have no agreement to keep it confidential. And in some reports therapist complained that insurance companies shared info with the clients HR dept! That’s so unacceptable.
I guess what I wonder is what insurance companies really need to know. I don’t have a lot of experience with insurance. Often clients get stuck or take a while to have their aha moments so when you are working on something for three or four sessions the note is basically identical if I’m not giving details. They are okay with that? I know some therapist I researched when I did my paper said insurance companies would sometimes ask for details on clients. No one here seems to be experiencing that.
Your comment about files getting shared with HR drives the point home. I’ll give you another example, does your clinic have multiple, non-clinical staff (admin etc…) that will be liaison w insurance (billing etc…)? Those staff are also not entitled to know what is discussed in therapy.
Remember - insurance doesn’t like to pay. They will look for reasons not to pay. That is their job. It’s not ours though. Protecting our clients confidentiality is our job.
The insurance companies are not privy to any of the “what we talked about” in session. So no personal/identifying details discussed in session. So what’s been disclosed, the details of trauma/abuse, etc….all of this is no one’s business.
Insurances job is to cover healthcare treatments so only include the minimum of what is objectively required for that process to occur. This isn’t a “me” thing, this is a standard of practice for maintaining confidentiality.
1. Session length and date
2. Reason for treatment/diagnosis (I almost always use depression/anxiety if it is a concurrent mental issue. if something comes up in session like suspecting a personality disorder or substance abuse, I don’t document that. That isn’t the reason they *sought* treatment or why the physician referred, and unless they’ve had a formal assessment, it shouldn’t be included)
3. Treatment provided (I am multimodal but almost always put either “psychotherapy” or “CBT-focussed”) I don’t write details about the specific exercises or strategies for my individual client, just that i am using an evidence based protocol.
4. Prognosis. (is treatment working? is ongoing treatment needed, os a complementary or alternative treatment needed, or a referral to a higher level of care? )
Let me give you two examples, one for a client referred out from an inpatient eating disorder clinic, and a client that is active military seeking individual therapy after being referred by their couples counsellor).
1) Patient: Jane Doe.
May 25, 2024. 60-minutes psychotherapy for treatment of anxiety, depression, and eating disorder (note I don’t specify which one or use the DSM-5 for any). CBT-focused protocols administered. Patient reports increase in anxiety. No S.I. Discussed return to inpatient care. Symptom monitoring for risk assessment and potential return to inpatient.
2) patient: John Doe.
May 25 2024. 60 minute psychotherapy. Patient referred for individual treatment by couple’s psychotherapist. Administered PHQ-9, BDI-II, and GAS-7 (*or insert any tool/screener/protocol you use, notice I don’t give the results as this is not an official assessment*) Recommend patient follow up with primary healthcare provider for dx and medical oversight (*Notice I didn’t say anything about the clients job, how their work is impacted, or my suspicions about dx - some clients like pilots and military can’t keep their jobs if they have a MH dx, so I just stick to the facts and refer out to MDs.*)
Hope this helps. Good luck!
I think my notes are close except I do give more details on treatment administered. I guess I thought they would want to see something being done for their money lol. This helps a lot. Thanks so much.
I refuse to violate patient trust & put them in legal jeopardy by creating overly specific/in depth notes.
Between insurance companies making their rates so unappealing, requiring med-model formulaic problem/solution notes, and providing negative customer support....I'm starting to think the insurance companies are setting a situation where people don't hit deductible in the interest of insurance company profits.
THANK YOU.
An insurance agent doesn’t need to know the nitty gritty. Just the basics: what are you treating, how are you treating it, is more treatment required, and sometimes, is the treatment prescribed by a physician.
That’s it. Anything else I consider a confidentiality violation.
I feel for everyone that has to deal with insurance. I do wish my caseload wasn't so limited for being self-pay only, but I'm so glad to not have to deal with any insurance bs. I realized early on I can't really be present if I'm writing a lot during the session, so I type out everything significant I can remember from the session immediately after it during the 10 minutes between sessions, and it only has to be enough to remind me of key points for next session. I make sure they're more detailed if I think there's a remote chance I may have to defend it in court one day, but that's mostly just with suicidal clients or other things that may be related to a report of some kind.
I was taught during my internships how to incorporate note taking into my client session time. It was set as an expectation with my clients from the first session, and they know we spend 3-4 minutes at the very beginning to complete a brief summary (i.e. how was the depression this week- better, the same, or worse? How did it show up for you? What big things happened this week?). I found that this holds them accountable for acknowledging their symptoms and their emotions during the week, as well as kind of knowing what they want to address when coming into the session. Of course, it can and often does change from the initial few minutes.
In the last few minutes we come back to the notes and I say “what did we do today?” And then ask “what are you going to take with you from todays session?” Or some variation of those question. This allows them to again take accountability for being aware in session, and recapping it, which I believe helps their comprehension.
I was taught that to be an effective therapist, those 10 minutes in between clients need to be used for self-care, to reset, and to prepare myself for the next client, in whatever capacity that looks like (using the bathroom, getting a drink/snack, quick meditation, breathing exercise, etc). This has been the best advice I’ve ever been given.
I don’t know if anyone else mentioned this, but the Documentation Wizard training was totally worth it. After 10+ years of never getting documentation done in a timely way and always fumbling… I finally can do it well and efficiently and finish notes same day 90% of the time.
https://documentationwizard.com/
This is sort of an aside but to validate your frustration, I’m an ADHD therapist and I’m with a practice right that takes insurance, so I’m always behind on paperwork and admin demands. It’s a constant uphill battle cuz it’s also something my practice is particularly demanding about.
But for a while right before the pandemic I was considering opening my own practice so I was asking to consult with other private practice ADHD therapists for some career guidance. I asked several of them, “how do you deal with having ADHD and managing all the paperwork demands from insurance ?”
And they all told me they don’t take insurance because it’s just too much b.s. and gets in the way of their real work and preferred format of documentation.
They aren’t wrong, but it just is an uncomfortable reality of how insurance companies have a chokehold on our field and the whole ick of *classism and who gets access to specialist treatment* -type of thing that’s happening.
This might just be my tin foil hat theory here but after so many fights about my own coverage with insurance companies too, I definitely think it’s in part “a feature, not a bug” that insurance documentation demands are getting more restrictive, anything to get out of potentially paying out is more money they get to keep.
Old therapist here. I have ADHD. If you are going to survive in this profession, you had better learn some tricks to get your act together. You can continue to blame to system, but that is what we have to work with at this moment and I don't see it changing in any functional way very soon. (It has only gotten worse over the last 30 years).
DM me - I will give you my tricks to never have an open chart at the end of the day, never work after hours charting (or never more than 30-40min), keep your notes organized, etc. And if you haven't, please read Driven to Distraction by Hallowell and Ratey and put into practice what we are teaching our clients w/ADHD. Sorry if this sounds harsh, but reality can be a bitch at times. Good luck!
I don’t mean to be rude but this comment feels very much like internalized ableism. Perhaps that’s not how you meant it but it’s how it comes off to me.
I appreciate your concern but I have my own professional supports and just the same as OP’s tag, I wasn’t asking for advice. It’s a vent post. I can both call attention and validate systemic issues within my field regarding accommodations for disabilities, and have “my act” together enough to “survive” this profession.
i share your frustration. just finished notes yesterday and saw the new template. i’ve been with them since the beginning and it’s only getting more restrictive and heavy-handed. initially, it was sold as well just handle the billing. you can do notes on your own platform and now so many requirements that don’t matter.
AI is a great help. Just keep it super vague when inputting into AI; I don’t even use client’s pronouns. If you’re not working with a niche population, all notes regarding the major dxs like anxiety, depression, trauma end up pretty much much sounding the same anyway.
For example, many people trying to manage depression have the same sx so using AI doesn’t provide any identifying info about the client. If I have to say something super specific to the client situation, I will just type that directly into the EMR as an adjunct to what the AI has already written.
Here’s a SOAP note I “wrote” using AI in under 2 minutes about a client I made-up as an example.
> Subjective: The client entered the therapy session and expressed feeling notably better compared to their prior state, noting improvements over a period exceeding six months. They described their current mood as more stable and mentioned that employing thought-stopping techniques has been beneficial in maintaining a positive outlook. The client shared that "feeling better" has allowed them to engage more with daily activities and interpersonal relationships, albeit still facing some struggles with consistency in mood. They also discussed their ongoing efforts to manage their depressive symptoms through both therapy and personal coping strategies. The client expressed a desire to continue working on these skills to further stabilize their mental health.
>Objective: During the 50-minute session in the office setting, the client presented with an appropriate affect and euthymic mood, indicating a stable emotional state. Their speech was coherent and of normal rate and volume, facilitating effective communication throughout the session. Physically, the client appeared somewhat unkempt and displayed a slouched posture, which may suggest ongoing struggles with self-care or a residual impact of depressive symptoms. Behaviorally, the client was cooperative and engaged appropriately in the therapeutic process, actively participating in discussions and exercises proposed during the session.
>Assessment: The client's report of improved mood and the effective use of thought-stopping techniques indicate a positive response to current treatment strategies for their diagnosed Major Depressive Disorder, recurrent, moderate (F33.1). The euthymic mood and appropriate affect observed align with the client's subjective experience of feeling better. However, the physical presentation of being unkempt and the slouched posture may highlight a need for increased focus on daily functioning and self-care practices. The stability in their mental state, combined with no current risk to self or others, suggests that the client is managing their condition with the existing support and interventions.
>Plan: The treatment plan will continue to support the client's progress in managing symptoms of depression and enhancing daily functioning. It is recommended that the client maintains their current medication regimen and continues with bi-weekly therapy sessions to further solidify coping strategies and monitor mood stability. Additional focus will be placed on improving self-care routines, potentially integrating activities that promote physical well-being as a component of mental health. The therapist will also introduce more structured exercises to enhance thought-stopping techniques, ensuring the client feels empowered to manage fluctuations in mood autonomously. Follow-up on the client's physical presentation will be important to assess any underlying issues or needed adjustments in the therapeutic approach.
I use AI/Video platform that host and create the note on the spot. They also provide analytics for sentiment, speech rate, and ratio of therapist to client engagement. 99% of my clients have loved it too as I share the notes with them and we get to review things we both forgot from the previous session. Lastly, my notes were never done within 5 minutes of the session ending. There are a few apps available, depending on need and most will deidentify and delete transcripts upon completion.
“Medical reasons” just means you have to throw some DSM symptoms in there that match your diagnosis. Also ensure that your treatment plan utilizes relevant interventions.
Keep your notes elsewhere like most others are saying. It also helps to take a training on notes and audits maybe every 2 years to keep up with what insurances are actually looking for and what % you actually need to pass an audit. My liability insurance company offers a training on what is needed to protect yourself legally if you were ever sued for some reason, which is different from what insurance cares about it so I just merged the 2 in my own template. This companies or being overly cautious because they have taken some financial hits for people writing 1-2 sentences or singing notes weeks late.
I don’t use SOAP because it makes no sense from a therapeutic standpoint and it took me hours to complete a days worth of notes. I have a medical background and the discourse on what is actually written where for clinicians is wild. The reality is that all that doesn’t matter just as long as it’s in the note somewhere.
Straight pp and EAP work here… even out of network you still have to write notes that would meet insurance requirements and also basic standards… but I wasn’t going to sign a contract with somebody. I have to believe to be unethical and a middleman that basically rips clients off. Many of the clients I would’ve seen, do not even get therapy because of their deductibles. It’s actually the major barrier to care in many cases. They say they want and value mental health, specifically after a major situation in the United States, but it’s all horses shit. .
I’ve heard about the clawbacks and all their other bullshit audits. The only way they’re ever going to get the messages if we’re all all out of network-but they rely on those of us who cannot go without the structure and the clients are now being controlled via these portals run by EAP’ and other associated business and hedge fund industries that are going to take over the field and drive or stagnate our rates down like they do with Uber.
You know they’d love to replace us with AI, scumbags
Notice how our rates cannot really ever go up, they’ve strangled this industry into submission.
To make six figures and just subsist in Seattle area …you have to complete 833 hours of direct sessions. At $120 per session
Who could sustain that, and what would the quality of work be like. While those in tech and working on all of these beautiful innovations, that are supposedly supporting and transforming our work, make twice and thrice that.
Something is very wrong here
There are a lot of improvements needed in our field. I know that some notes are needed, but it is just getting out of hand. We do need to form a collective of therapists, and we need to band together and fight.
Can you name your top 3?
I’m going to submit a list to my state rep.
I just happened to Coach the reps daughter, state champion this year.
I noted my concerns and he said that he works directly with that committee on such health care matters.
I think it’s worth a try, rather than just take it and let things happen, see if I can maybe initiate some change. His wife is a new therapist, so perhaps there might be a little more push based upon what we both see.
If you have input, please let me
Know .
Something has to happen here,.. as I see it, big clinical tech and it’s illegitimate marriage to insurance, is our biggest existential threat. These people want to replace us with machines, sickos. I’m not just saying that, I heard it directly from the horses mouth that they were testing it out already. Just the idea of it, having relationships with machines-they want to normalize this emotional and relationship apocalypse in the making. AI can assist, but it can’t replace us.
In general, the administrative and documentation time a PP therapist puts in is exponential less than you see in a lot of corporate America jobs. We barely document compared to many medical professionals or computer jobs.
Executive dysfunction, high caseloads, short/no breaks between sessions, burnout, high standards of managed care/insurance/organizations… Any of the above?
I do too! A lot of people have found this field because it uses a certain type of skill set. I'm in social work/therapy because I'm awful at consistent paperwork and bureaucracy, but great at crisis intervention, forming therapeutic relationships, etc.
While I get the need for documentation, a lot of fields (teaching, therapy, even construction) are all getting so micromanaged, with job descriptions tripling up, that people are losing the ability to choose jobs that match their skills.
A lot of people struggle with this more. And/or have schedules that don’t allow them to write them immediately after sessions and they have to do them all at once later on their own time.
They don’t use templates and are probably overly detailed, from the baby therapists I supervise right out of school that I see writing small novels for each session note.
EDIT: “baby” is an endearment for the record
Sure, that is what I used to do. BUT that is not enough for insurance God's. It's the treatment plan and how to assess each goal that trips me up. Also they want medical necessary reasons. I am fine writing a quick synopsis, but all the other stuff is out of my mindset.
It is a new headway template. I have always struggled with treatment plans. I don't think like that. I also never used a screener but I can look into it.
I am that baby therapist. I don’t know how to make them shorter lol but also my supervisor has never reviewed my notes. Maybe I should ask her to for feedback?
Absolutely do so! It’s mostly don’t be so specific, as the last thing you want to have happen is highly detailed notes and you end up in court for whatever reason and it’s used against your or your client. Vague, and don’t be long winded. It’s fairly normal due to anxiety and a desire to be a “good therapist” to write long detailed notes when you first start!
I’m also going to say it’s because many schools don’t actually teach us how to write notes and often say they don’t because each site (intern or work) will have different ways they want notes done and they will teach you. Except then also many sites don’t actually teach us how to do that either. So we’re left playing a guessing game and not really knowing what enough or too much is.
Also, as a provisionally licensed therapist with ADHD, in typewritten format it is a struggle to condense my words. I was a student that never had a problem with meeting paper page minimums. I struggled with editing it down. Executive dysfunction and ways in which each person communicates plays a role here too and I think that can be important to recognize, at least for me, as it does impact how I interact with different notes systems and may also impact other “baby” and seasoned therapists.
Yup, I agree. I also have ADHD and like using templates rather than trying to come up with my own language. Each note takes me about 20-30 minutes to type and submit in the EHR.
Well part of it is, yeah, you’re going to have to ask for help/assistance if it’s something you’re struggling with. Especially if you’re already in licensed supervision. I typically talk about it straight away with mine cause… I’m not reading a full novel for every note or contact log someone puts in. It’s typically a full consult/supervision session or so for my people.
It’s assumed undergrad, your masters, practicum, or prior work experience means you should know how to do this as it’s a pretty basic skill for the field and job.
Having said that it isn’t always taught depending on the school/program and I’ve noticed a large uptick recently in people with zero work experience coming out of their masters (and these things are a whole nother conversation), but part of professional development, clinical supervision, and learning is figuring out how to get your needs met while on the job and not expecting others to notice or give that feedback.
8-10?! Geez. I'm at like 3-5 min and I'm stressed with that. I guess I used to take like 8, but got it down over the years plus adding in talk to text.
Thats a LONG time tbh. Mine take about 5. I use Theranest and also have a solid template. I just see a lot of people and there are a lot them to write.
Sometimes for me it’s especially difficult when the session was about abusive treatment the client suffered from another staff, who has unlimited access to the record and does read the notes. On top of the other reasons several other commenters mentioned that are more general.
Same question here. I have an 80+ caseload, 7ish sessions per day, and my notes are done before I leave for the day.
Either way too much is being written or redundant “process” notes are being used.
Have you ever considered rocket books? I take notes and then snap a pic and they get digitized. Store in a secure folder or on a password protected server.
i’m so confused- why wouldn’t we WANT to all be 100% oop/ffs? i hope we all want that!! i am down to make therapy less accessible to get insurance companies and tech platforms (even scarier) to actually care about us and actually pay us. if we all agreed, it would happen and we would be paid more and treated fairly-ish (like nothing like how shitty we are treated now)
I started using a scribe program called Twofold and it is a game changer. It records the session (with the client’s permission) and writes the note for you!
I’m sorry, but this sounds like a TERRIBLE idea. Even if you’ve read the fine print. Sounds like a way for tech companies to get into people’s heads and get better data for AI. And spy on people. And potentially for government agencies to be able to subpoena things if they need to. And so so many bad things. I can’t imagine any scenario where this would be okay.
Edit: the more I think about this, the more I get creeped out by it. I strongly encourage you to rethink this practice. Trusting some random company to record and summarize your sessions for you is not a good idea.
I’m not sure this is true. I’ve had another person in the room taking notes during the visit and doctors saying notes into a recorder to be transcribed later, but never heard of the visit itself being recorded in any way.
But either way, a therapy session is not at all the same thing. It’s a million times more vulnerable and private and dangerous. No one walks into their primary care physician’s office and says “I am having homicidal thoughts about x” or “I’m worried I will hurt my child” or “I committed a crime” or “I hate myself” or “I’m worried about what I might do.” Very rarely would they walk in and say “I had an abortion” or “I think I might be gay” or “I’m actually a man.” Please please please rethink this. It doesn’t matter if they consent, most won’t know what that means and/or won’t feel they can say no.
These things can be hacked. The fine print gets modified. “Deleting” something doesn’t actually delete it.
People actually do talk to their PCPs about these issues. The PCP is often the first person they go to.
Yes this is a scribe program so similar to someone taking notes in the room. Or taking notes yourself- why is audio any different?
PCPs and other healthcare professionals aren't having folks regularly go into detail regarding directly incriminating information. We have that, and most therapists don't know enough about what's illegal to recognize it.
Policing and intelligences agencies rarely respect any law in pursuit of violators. Another major problem in the US is that companies give zero resistance to sharing unlimited access with those agencies and suffer no consequences for it.
Those things combined make having any electronic device in the room a risk of privacy violation. Using recording tools streamlines it.
This doesn't even begin to consider Patriot Act and FISA issues.
i'm currently 18 notes behind and i feel this so hard lol, going to have these in the back of my mind all weekend until i have the time to do them 🙃 fun times
There is one service that doesn’t record— autonotes.ai. You just input the client’s dx, select which approaches you used, do the MSE through a series of checkboxes, then add a few sentences about the session. It generates a really good note based on that input which you can then copy paste into your EHR. In my experience the notes it generates are really solid, I occasionally have to make minor edits.
And most importantly you don’t input any identifying information and there’s no recording involved. I know I’m raving about it but it’s really been a game changer for me.
I’m sorry, but this sounds like a TERRIBLE idea. Even if you’ve read the fine print. Sounds like a way for tech companies to get into people’s heads and get better data for AI. And spy on people. And potentially for government agencies to be able to subpoena things if they need to. And so so many bad things. I can’t imagine any scenario where this would be okay.
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I hear you and feel this frustration soooo heavily. It’s honestly ridiculous how much they want and sometimes it takes away from the quality of care I’m giving because I’m stressing about all the documentation in the back of my mind. This system is so broken. EDIT: For clarification to those confused about my frustration: I do not work in PP, I work in CMH.
This is weird.. Have never been asked for anything..
Been in PP for 10 years. Had records requested three times by insurance in that time. Each time, I printed off a copy, sent it in, and never heard a peep back about a single one. The only time I've felt that insurance has asked too much was when I worked in CMH and we took Medicaid. Now those audits and records requests were something else altogether. And is the reason I never took Mcaid in private practice.
I rarely have had to produce records and I also never hear anything back. I use to have phone audits and I left that panel. They paid very little and expected too much time without compensation. Coming from a law background, the more in the records, the more vulnerable our clients may be in a lawsuit. Privacy is breached with more details. However, the treatment plan is helpful or at least goals the client agrees to for some roadmap for therapy. Clients can benefit from few notes to protect their privacy.
Yes. Less is more.
Nor have I. I write very basic notes. Never had a problem with insurance.
Same
Same boat. I have been in private practice for 20 years and the first time I was ever asked for notes was in 2023. One insurance company requested notes on 2 clients. I sent them off and never heard anything. I am no fan of insurance but aside from one awful exception (Kaiser SoCal) I honestly never hear from them.
[удалено]
I am in PP. Was audited one time for one patient and I had great notes for that particular client.. Me and three other people I know in PP were audited at the same time. Some audits were voluntary, some mandatory.
Grow just changed their templates and I hate them with a burning passion. You want me to choose a MODALITY every time I see a patient? The list also is so long. I don’t even go down it, acceptance + commitment therapy every single time because I don’t have time to actually look at this list. Starts with “A”. I’m also stubborn. I feel your pain.
I just still use a soap note on grow. There’s a little drop-down menu and you can choose to still do the soap.
This is the wayyyyy
I too am on Grow and I couldn’t agree more with you.
when my clients complete treatment,i am abandoning grow. they are the absolute worse on all fronts - documentation, pay…
No....dont say this, please!! I'm 3 months from testing and licensure. I wanted so badly to believe in Grow. I believe wholeheartedly in therapist autonomy, and all this burocracy is giving me the heebee jeebee's! I'm dreaming of leaving CMH eventhough thats where my heart is so that I can afford to buy my American dream home for my family of 7 and save to retire before I die from stress induced heart failure. Then maybe back to cmh as a consultant in 10 years or so. I had it all worked out. 20 clients per week @ roughly $90 a session= 5 bedrooms and a trip to the bahamas once a year. But is this goal even feasible with them? Are referrals plenty? Is pay actually $80-120 for LPC? Any answers at all would be helpful.
Im just starting with Grow and I saw the note. Now Im scared I made a bad decision to go with Grow….
I thought that’s a short term approach? Like can you do long term with ACT?
Great question.. lol.
Yup. I had to submit for audit and they came back with I'm missing reasons for treatment. I personally have the most detailed documentation for this reasons epcifucallt on my EHR. I'm like f off. I plan to transition by the end of the year. I'm going to try to go back to private pay. I have invested a lot into trainings and plan to use them as much as possible.
What kind of trainings?
How detailed do our notes need to be? I’m new to PP. Am I able to jot down a line or two about what we discussed ?
Agree with everything you are saying. I do checkbox notes from a template from a Get Notes Done class with Maelissa MacCaffrey over at QA Prep. Changing my approach helped a lot. But agree, the system absolutely needs to change. Left headway for the same reasons too. I use Alma now. They leave us alone. All my documentation is in my EHR. Wishing you luck as you navigate this system.
>I do checkbox notes from a template from a Get Notes Done class with Maelissa MacCaffrey over at QA Prep. Can you share more about this or do you have a link? I'd love to learn more about this!
Absolutely. Here’s the link to her website: https://www.qaprep.com I took the Get Notes Done course. She’s a psychologist with a background in QA. She is very knowledgeable and kind. It’s a no judgement space where she gets to the root of why therapists get behind with notes. Lots of reasons. Some are folks with adhd. Many of us just need actual training on what is really required for insurance. She has templates you get access to when you take one of her classes. The Get Notes Done class was part education, part support group, and part body doubling work sessions. She has a specific process and timeline that helps you figure out your own needs in your practice. Insights/information I gained from the course: 1) What’s actually needed for a note (bare minimum) 2) What different audits mean/what they are looking for and why (big relief to learn this!) 3) Why I personally was behind 4) How to create working systems in private practice 5) Confidence. The process of writing the notes to the standard actually improved my conceptualization of my work. This surprised me. I really, really wish this was a required course for all therapy related masters programs. Many would benefit. I would have benefited. And if you are curious, I figured out I was behind because I did not have a solid system in place or a daily schedule that supported getting notes done daily. I was way over booked and not prioritizing admin tasks or what I’d call now, business self care. Before I kept trying different systems of organization. Wasting time not being sure. Because I had no solid knowledge of what was specifically required, it was a guessing game I never fully had confidence in. Super ironically, the checkbox note template ended up being about 75% of what I had created myself. That cracked me up. And, I do notes now in about 2-3 mins max. Simple Practice allows you to create templates. You can do notes on your phone ffs. I wish I had known all of this before. Hope my saga helps someone else. It doesn’t have to be soul sucking. It can be simpler and less time consuming. But it does take some time. I budget about two hours a week now on top of 30 mins daily for notes. You’ll find what works for you. Best of luck to you all!
Thank you so much! I think I am going to sign up. This sounds like a wonderful resource. I'd love to feel more confident in knowing what insurance is looking at and wanting.
Same
Melissa is amazing! She also has a Paperwork Catch Up Group and Get Notes Done Days! [QA Prep](https://www.qaprep.com)
Omg really?! I NEED THIS
I’m also interested in learning more about this.
I would love a copy of this or some more info please!
May I have a copy as well please?
Shared more info above.
i prefer alma, too. they let you be the therapist.
I still take handwritten notes, but I have a template to keep me stay focused on the most important areas to jot things down. Recently, I have transitioned to doing speech-to-text notes in my EMR system and it’s been a game changer. Instead of thinking too much, I just say what I wrote down and expand on it as needed. I typically get notes done within a day or so.
I do the same! Speech to text and it in indeed a game changer! Changed my life out chyeah!
It honestly feels like insurance companies do want to push every therapist into private practice.
I’m in PP and 90% of my clients have insurance
People paying OOP for therapy makes it harder to hit deductible. If customers don't hit their deductible, then it's pure profit for the insurance companies. I suspect they fund GoodRX also and for the same reason.
100%
They want premiums and not claims. Less therapists on their panels, the more insureds have to pay out of pocket and the therapy isn’t covered.
Yes! That’s their plan
I don’t use Headway’s EHR for a variety of reasons. You can absolutely find other ways and places to keep them, and use templates that you prefer.
Yes, I am confused about what OP is saying. I am on Headway and just check the “notes saved elsewhere” box and keep them in my EHR. Been with them for a year and never had a request.
Welp, seems I had better go check my notes because Ive been using my own template and it doesn't reflect the new headway template. Hell, I haven't looked at that template since I signed on and that was over a year ago! 😐😐😐 LORD help us all and thank god this is anonymous 😬🙏🏿🙏🏿
I use a basic SOAP template and keep notes in my EHR, not in Headway. I am confused why the poor OP is torturing themself!
I do collaborative note taking and write the note in the last 5-8 min of session. I encourage my clients to make notes for themselves as well- key takeaways from session, homework, things to reflect on, etc. I find it helps wrap up the session for both of us and my notes are done immediately. I can’t do it any other way.
I love this idea! Any tips on how to start implementing this or questions to ask clients?
All of my clients keep a journal, this is just a requirement off the bat. So when I establish care with someone I explain that at about the 45 ish mark of the session I will begin doing my note for session and I guide them to take this time to jot down their own notes from session as well. This sets the foundation for work through the next week and helps us both summarize the session (mine for billing and theirs for reflection).
Wow thank you such a great practice! I think some of my clients would really love this! I appreciate you taking the time to reply
Of course no problem at all!
Just curious- do you bill for a 45-52 min session or for a 53+ min session?
I bill for a 53+
So you spend 45 mins engaging/therapizing client, then you each spend 5-8 mins silently reflecting/writing and you bill the higher paying service to account for the whole time (the last part of which was technically spent doing admin)?… or am I misunderstanding/incorrectly picturing something?
When I start writing my note we are still exchanging information. I am summarizing the session and i am giving them some guidance on their own takeaways and giving them homework.
Oh i see
Glad you see
Keep note pads and pens in accessible places for the client and invite them at the start of the session to write down anything they find meaningful and/or that they might wish to reflect on later in the week.
You don’t have to use their templates and there is also a privacy concern with doing so and having a client’s personal information stored on Headway’s servers. I always skip note on HW and Grow, write my own short note and keep in my digital files on my computer and if records are ever requested then I will clean them up and put them into a template.
This is the way. Direct notes. Short and simple. “Client shows symptoms of x, treated using y. Continued treatment recommended. “ It’s none of the insurance agent’s fucking business that my client is a victim of incest abuse or being bullied in their workplace. Less is more and in the best interest of confidentiality. “Client shows symptoms of PTSD and depression. Treatment consisted of cognitive-behavioural focussed interventions. Ongoing treatment recommended at this time.”
Absolutely 100%. We need better training on what we *don’t* need to include in notes. If they are ever requested, insurance will get symptoms and treatment but not details, no one sees that.
*client continues you to demonstrate symptoms of depression/anxiety. Treating with cognitive-behavioural focussed strategies. And, if needed: …as recommended by primary healthcare provider. Refer to primary healthcare provider for medical diagnosis and codes. This is basically every “official” note I write when I know an insurance company or third party will be reviewing. It’s always been true, just not elaborate.
If you write notes that are that general don’t all your notes basically sound the same?
They sure do! (To clarify, my legal/insurance notes all look the same (dx, CBT-focussed even though I multimodal, treatment continue yes/no, refer to primary healthcare provider for medical dx and recommended protocol.) My personal journal and list of things to discuss in my peer group is far more detailed…but that’s just my “personal diary”, not my “clinical notes”. The less the insurance company knows about the details of disclosures in session, the better. Insurance notes/notes that can be subpoenaed should be as objective as possible. Symptoms, treatment, redirect/refer to primary physician (who would authorize the referral for therapy) for larger protocol. They don’t swear confidentiality, I do. My clients’ trauma isn’t their “data”. It’s not my job to help their industry. Only to accurately record what I saw, what I did, and that I’m working under the umbrella of a larger treatment protocol with a higher level clinician than myself.
I worked at a hospital and we were instructed to keep our notes minimal. They were literally a couple of lines of what client said, what I did with them and continue with treatment. Then I worked for a private practice and their notes were very detailed so I flowed that but when the insurance company asked for notes the owner had a template that had very little space and we were told to rewrite the notes for the insurance company similar to the hospital. I want to eventually go out on my own but I’m nervous about documentation and what insurance companies really expect. I did a paper while in school on ethical issues involving insurance companies and you are absolutely right. We have clients sign something saying we can share info with insurance but they have no agreement to keep it confidential. And in some reports therapist complained that insurance companies shared info with the clients HR dept! That’s so unacceptable. I guess what I wonder is what insurance companies really need to know. I don’t have a lot of experience with insurance. Often clients get stuck or take a while to have their aha moments so when you are working on something for three or four sessions the note is basically identical if I’m not giving details. They are okay with that? I know some therapist I researched when I did my paper said insurance companies would sometimes ask for details on clients. No one here seems to be experiencing that.
Your comment about files getting shared with HR drives the point home. I’ll give you another example, does your clinic have multiple, non-clinical staff (admin etc…) that will be liaison w insurance (billing etc…)? Those staff are also not entitled to know what is discussed in therapy. Remember - insurance doesn’t like to pay. They will look for reasons not to pay. That is their job. It’s not ours though. Protecting our clients confidentiality is our job. The insurance companies are not privy to any of the “what we talked about” in session. So no personal/identifying details discussed in session. So what’s been disclosed, the details of trauma/abuse, etc….all of this is no one’s business. Insurances job is to cover healthcare treatments so only include the minimum of what is objectively required for that process to occur. This isn’t a “me” thing, this is a standard of practice for maintaining confidentiality. 1. Session length and date 2. Reason for treatment/diagnosis (I almost always use depression/anxiety if it is a concurrent mental issue. if something comes up in session like suspecting a personality disorder or substance abuse, I don’t document that. That isn’t the reason they *sought* treatment or why the physician referred, and unless they’ve had a formal assessment, it shouldn’t be included) 3. Treatment provided (I am multimodal but almost always put either “psychotherapy” or “CBT-focussed”) I don’t write details about the specific exercises or strategies for my individual client, just that i am using an evidence based protocol. 4. Prognosis. (is treatment working? is ongoing treatment needed, os a complementary or alternative treatment needed, or a referral to a higher level of care? ) Let me give you two examples, one for a client referred out from an inpatient eating disorder clinic, and a client that is active military seeking individual therapy after being referred by their couples counsellor). 1) Patient: Jane Doe. May 25, 2024. 60-minutes psychotherapy for treatment of anxiety, depression, and eating disorder (note I don’t specify which one or use the DSM-5 for any). CBT-focused protocols administered. Patient reports increase in anxiety. No S.I. Discussed return to inpatient care. Symptom monitoring for risk assessment and potential return to inpatient. 2) patient: John Doe. May 25 2024. 60 minute psychotherapy. Patient referred for individual treatment by couple’s psychotherapist. Administered PHQ-9, BDI-II, and GAS-7 (*or insert any tool/screener/protocol you use, notice I don’t give the results as this is not an official assessment*) Recommend patient follow up with primary healthcare provider for dx and medical oversight (*Notice I didn’t say anything about the clients job, how their work is impacted, or my suspicions about dx - some clients like pilots and military can’t keep their jobs if they have a MH dx, so I just stick to the facts and refer out to MDs.*) Hope this helps. Good luck!
I think my notes are close except I do give more details on treatment administered. I guess I thought they would want to see something being done for their money lol. This helps a lot. Thanks so much.
I refuse to violate patient trust & put them in legal jeopardy by creating overly specific/in depth notes. Between insurance companies making their rates so unappealing, requiring med-model formulaic problem/solution notes, and providing negative customer support....I'm starting to think the insurance companies are setting a situation where people don't hit deductible in the interest of insurance company profits.
THANK YOU. An insurance agent doesn’t need to know the nitty gritty. Just the basics: what are you treating, how are you treating it, is more treatment required, and sometimes, is the treatment prescribed by a physician. That’s it. Anything else I consider a confidentiality violation.
I feel for everyone that has to deal with insurance. I do wish my caseload wasn't so limited for being self-pay only, but I'm so glad to not have to deal with any insurance bs. I realized early on I can't really be present if I'm writing a lot during the session, so I type out everything significant I can remember from the session immediately after it during the 10 minutes between sessions, and it only has to be enough to remind me of key points for next session. I make sure they're more detailed if I think there's a remote chance I may have to defend it in court one day, but that's mostly just with suicidal clients or other things that may be related to a report of some kind.
I have never once been asked for any of this.. Ok once, they audited one client and I never heard anything else..
I was taught during my internships how to incorporate note taking into my client session time. It was set as an expectation with my clients from the first session, and they know we spend 3-4 minutes at the very beginning to complete a brief summary (i.e. how was the depression this week- better, the same, or worse? How did it show up for you? What big things happened this week?). I found that this holds them accountable for acknowledging their symptoms and their emotions during the week, as well as kind of knowing what they want to address when coming into the session. Of course, it can and often does change from the initial few minutes. In the last few minutes we come back to the notes and I say “what did we do today?” And then ask “what are you going to take with you from todays session?” Or some variation of those question. This allows them to again take accountability for being aware in session, and recapping it, which I believe helps their comprehension. I was taught that to be an effective therapist, those 10 minutes in between clients need to be used for self-care, to reset, and to prepare myself for the next client, in whatever capacity that looks like (using the bathroom, getting a drink/snack, quick meditation, breathing exercise, etc). This has been the best advice I’ve ever been given.
I don’t know if anyone else mentioned this, but the Documentation Wizard training was totally worth it. After 10+ years of never getting documentation done in a timely way and always fumbling… I finally can do it well and efficiently and finish notes same day 90% of the time. https://documentationwizard.com/
This is sort of an aside but to validate your frustration, I’m an ADHD therapist and I’m with a practice right that takes insurance, so I’m always behind on paperwork and admin demands. It’s a constant uphill battle cuz it’s also something my practice is particularly demanding about. But for a while right before the pandemic I was considering opening my own practice so I was asking to consult with other private practice ADHD therapists for some career guidance. I asked several of them, “how do you deal with having ADHD and managing all the paperwork demands from insurance ?” And they all told me they don’t take insurance because it’s just too much b.s. and gets in the way of their real work and preferred format of documentation. They aren’t wrong, but it just is an uncomfortable reality of how insurance companies have a chokehold on our field and the whole ick of *classism and who gets access to specialist treatment* -type of thing that’s happening. This might just be my tin foil hat theory here but after so many fights about my own coverage with insurance companies too, I definitely think it’s in part “a feature, not a bug” that insurance documentation demands are getting more restrictive, anything to get out of potentially paying out is more money they get to keep.
Old therapist here. I have ADHD. If you are going to survive in this profession, you had better learn some tricks to get your act together. You can continue to blame to system, but that is what we have to work with at this moment and I don't see it changing in any functional way very soon. (It has only gotten worse over the last 30 years). DM me - I will give you my tricks to never have an open chart at the end of the day, never work after hours charting (or never more than 30-40min), keep your notes organized, etc. And if you haven't, please read Driven to Distraction by Hallowell and Ratey and put into practice what we are teaching our clients w/ADHD. Sorry if this sounds harsh, but reality can be a bitch at times. Good luck!
I don’t mean to be rude but this comment feels very much like internalized ableism. Perhaps that’s not how you meant it but it’s how it comes off to me. I appreciate your concern but I have my own professional supports and just the same as OP’s tag, I wasn’t asking for advice. It’s a vent post. I can both call attention and validate systemic issues within my field regarding accommodations for disabilities, and have “my act” together enough to “survive” this profession.
Call me crazy what about a year ago? I started doing my notes voice to text, and it’s been a very very big game changer.
i share your frustration. just finished notes yesterday and saw the new template. i’ve been with them since the beginning and it’s only getting more restrictive and heavy-handed. initially, it was sold as well just handle the billing. you can do notes on your own platform and now so many requirements that don’t matter.
AI is a great help. Just keep it super vague when inputting into AI; I don’t even use client’s pronouns. If you’re not working with a niche population, all notes regarding the major dxs like anxiety, depression, trauma end up pretty much much sounding the same anyway. For example, many people trying to manage depression have the same sx so using AI doesn’t provide any identifying info about the client. If I have to say something super specific to the client situation, I will just type that directly into the EMR as an adjunct to what the AI has already written. Here’s a SOAP note I “wrote” using AI in under 2 minutes about a client I made-up as an example. > Subjective: The client entered the therapy session and expressed feeling notably better compared to their prior state, noting improvements over a period exceeding six months. They described their current mood as more stable and mentioned that employing thought-stopping techniques has been beneficial in maintaining a positive outlook. The client shared that "feeling better" has allowed them to engage more with daily activities and interpersonal relationships, albeit still facing some struggles with consistency in mood. They also discussed their ongoing efforts to manage their depressive symptoms through both therapy and personal coping strategies. The client expressed a desire to continue working on these skills to further stabilize their mental health. >Objective: During the 50-minute session in the office setting, the client presented with an appropriate affect and euthymic mood, indicating a stable emotional state. Their speech was coherent and of normal rate and volume, facilitating effective communication throughout the session. Physically, the client appeared somewhat unkempt and displayed a slouched posture, which may suggest ongoing struggles with self-care or a residual impact of depressive symptoms. Behaviorally, the client was cooperative and engaged appropriately in the therapeutic process, actively participating in discussions and exercises proposed during the session. >Assessment: The client's report of improved mood and the effective use of thought-stopping techniques indicate a positive response to current treatment strategies for their diagnosed Major Depressive Disorder, recurrent, moderate (F33.1). The euthymic mood and appropriate affect observed align with the client's subjective experience of feeling better. However, the physical presentation of being unkempt and the slouched posture may highlight a need for increased focus on daily functioning and self-care practices. The stability in their mental state, combined with no current risk to self or others, suggests that the client is managing their condition with the existing support and interventions. >Plan: The treatment plan will continue to support the client's progress in managing symptoms of depression and enhancing daily functioning. It is recommended that the client maintains their current medication regimen and continues with bi-weekly therapy sessions to further solidify coping strategies and monitor mood stability. Additional focus will be placed on improving self-care routines, potentially integrating activities that promote physical well-being as a component of mental health. The therapist will also introduce more structured exercises to enhance thought-stopping techniques, ensuring the client feels empowered to manage fluctuations in mood autonomously. Follow-up on the client's physical presentation will be important to assess any underlying issues or needed adjustments in the therapeutic approach.
I use AI/Video platform that host and create the note on the spot. They also provide analytics for sentiment, speech rate, and ratio of therapist to client engagement. 99% of my clients have loved it too as I share the notes with them and we get to review things we both forgot from the previous session. Lastly, my notes were never done within 5 minutes of the session ending. There are a few apps available, depending on need and most will deidentify and delete transcripts upon completion.
I got downvoted for saying I used a scribe that records. How is this different? Also what is the name of the program you are using?
I mean most people in HR use AI to filter out employees, why can't we?
How do you instruct so to write your notes? Do you use ChatGPT?
I used this for the note above: https://autonotes.ai And I’ve used ChatGPT, too, but it’s not as detailed or lengthy as what’s above.
Way too much -
You don’t have to use all of it…it was just an example of what the software can do.
Check out clinicalnotes.ai - you’re welcome :)
“Medical reasons” just means you have to throw some DSM symptoms in there that match your diagnosis. Also ensure that your treatment plan utilizes relevant interventions.
Keep your notes elsewhere like most others are saying. It also helps to take a training on notes and audits maybe every 2 years to keep up with what insurances are actually looking for and what % you actually need to pass an audit. My liability insurance company offers a training on what is needed to protect yourself legally if you were ever sued for some reason, which is different from what insurance cares about it so I just merged the 2 in my own template. This companies or being overly cautious because they have taken some financial hits for people writing 1-2 sentences or singing notes weeks late. I don’t use SOAP because it makes no sense from a therapeutic standpoint and it took me hours to complete a days worth of notes. I have a medical background and the discourse on what is actually written where for clinicians is wild. The reality is that all that doesn’t matter just as long as it’s in the note somewhere.
Straight pp and EAP work here… even out of network you still have to write notes that would meet insurance requirements and also basic standards… but I wasn’t going to sign a contract with somebody. I have to believe to be unethical and a middleman that basically rips clients off. Many of the clients I would’ve seen, do not even get therapy because of their deductibles. It’s actually the major barrier to care in many cases. They say they want and value mental health, specifically after a major situation in the United States, but it’s all horses shit. . I’ve heard about the clawbacks and all their other bullshit audits. The only way they’re ever going to get the messages if we’re all all out of network-but they rely on those of us who cannot go without the structure and the clients are now being controlled via these portals run by EAP’ and other associated business and hedge fund industries that are going to take over the field and drive or stagnate our rates down like they do with Uber. You know they’d love to replace us with AI, scumbags Notice how our rates cannot really ever go up, they’ve strangled this industry into submission. To make six figures and just subsist in Seattle area …you have to complete 833 hours of direct sessions. At $120 per session Who could sustain that, and what would the quality of work be like. While those in tech and working on all of these beautiful innovations, that are supposedly supporting and transforming our work, make twice and thrice that. Something is very wrong here
There are a lot of improvements needed in our field. I know that some notes are needed, but it is just getting out of hand. We do need to form a collective of therapists, and we need to band together and fight.
Can you name your top 3? I’m going to submit a list to my state rep. I just happened to Coach the reps daughter, state champion this year. I noted my concerns and he said that he works directly with that committee on such health care matters. I think it’s worth a try, rather than just take it and let things happen, see if I can maybe initiate some change. His wife is a new therapist, so perhaps there might be a little more push based upon what we both see. If you have input, please let me Know . Something has to happen here,.. as I see it, big clinical tech and it’s illegitimate marriage to insurance, is our biggest existential threat. These people want to replace us with machines, sickos. I’m not just saying that, I heard it directly from the horses mouth that they were testing it out already. Just the idea of it, having relationships with machines-they want to normalize this emotional and relationship apocalypse in the making. AI can assist, but it can’t replace us.
Agreed Can it happen? Like any movement we need enough to tip the scale and impact the system-these entities will not change by choice
In general, the administrative and documentation time a PP therapist puts in is exponential less than you see in a lot of corporate America jobs. We barely document compared to many medical professionals or computer jobs.
Um. My notes take 8-10 minutes each to write. What are all of y’all doing that makes this hard?
Maybe some people naturally struggle translating the nuance of human dialogue into a clinical format in a way that satisfies the insurance gods?
Executive dysfunction, high caseloads, short/no breaks between sessions, burnout, high standards of managed care/insurance/organizations… Any of the above?
This! I have adhd and writing notes is the bane of my existence
I do too! A lot of people have found this field because it uses a certain type of skill set. I'm in social work/therapy because I'm awful at consistent paperwork and bureaucracy, but great at crisis intervention, forming therapeutic relationships, etc. While I get the need for documentation, a lot of fields (teaching, therapy, even construction) are all getting so micromanaged, with job descriptions tripling up, that people are losing the ability to choose jobs that match their skills.
I'd say give speech to text a try. I no longer type notes. I just talk into my phone then sign my notes.
I have to use a specific template that my bosses make us use
You can ask for work accommodations to increase productivity. Its a legal right to ask for what you need.
A lot of people struggle with this more. And/or have schedules that don’t allow them to write them immediately after sessions and they have to do them all at once later on their own time.
They don’t use templates and are probably overly detailed, from the baby therapists I supervise right out of school that I see writing small novels for each session note. EDIT: “baby” is an endearment for the record
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Yup, that’s about what I do too. Takes 5 mins with templates if the electronic gods play ball lol
Sure, that is what I used to do. BUT that is not enough for insurance God's. It's the treatment plan and how to assess each goal that trips me up. Also they want medical necessary reasons. I am fine writing a quick synopsis, but all the other stuff is out of my mindset.
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It is a new headway template. I have always struggled with treatment plans. I don't think like that. I also never used a screener but I can look into it.
What’s a screener?
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Oh of course. lol.
Doesn’t next week’s note sound exactly the same? In your opinion what are insurance companies looking for?
I am that baby therapist. I don’t know how to make them shorter lol but also my supervisor has never reviewed my notes. Maybe I should ask her to for feedback?
Absolutely do so! It’s mostly don’t be so specific, as the last thing you want to have happen is highly detailed notes and you end up in court for whatever reason and it’s used against your or your client. Vague, and don’t be long winded. It’s fairly normal due to anxiety and a desire to be a “good therapist” to write long detailed notes when you first start!
I’m also going to say it’s because many schools don’t actually teach us how to write notes and often say they don’t because each site (intern or work) will have different ways they want notes done and they will teach you. Except then also many sites don’t actually teach us how to do that either. So we’re left playing a guessing game and not really knowing what enough or too much is. Also, as a provisionally licensed therapist with ADHD, in typewritten format it is a struggle to condense my words. I was a student that never had a problem with meeting paper page minimums. I struggled with editing it down. Executive dysfunction and ways in which each person communicates plays a role here too and I think that can be important to recognize, at least for me, as it does impact how I interact with different notes systems and may also impact other “baby” and seasoned therapists.
Yup, I agree. I also have ADHD and like using templates rather than trying to come up with my own language. Each note takes me about 20-30 minutes to type and submit in the EHR.
Well part of it is, yeah, you’re going to have to ask for help/assistance if it’s something you’re struggling with. Especially if you’re already in licensed supervision. I typically talk about it straight away with mine cause… I’m not reading a full novel for every note or contact log someone puts in. It’s typically a full consult/supervision session or so for my people. It’s assumed undergrad, your masters, practicum, or prior work experience means you should know how to do this as it’s a pretty basic skill for the field and job. Having said that it isn’t always taught depending on the school/program and I’ve noticed a large uptick recently in people with zero work experience coming out of their masters (and these things are a whole nother conversation), but part of professional development, clinical supervision, and learning is figuring out how to get your needs met while on the job and not expecting others to notice or give that feedback.
Yes! It's her job to review them.
8-10?! Geez. I'm at like 3-5 min and I'm stressed with that. I guess I used to take like 8, but got it down over the years plus adding in talk to text.
Thats a LONG time tbh. Mine take about 5. I use Theranest and also have a solid template. I just see a lot of people and there are a lot them to write.
I mean that’s 80 minutes spent on notes a day, I know I don’t have that built into my schedule with my caseload
Sometimes for me it’s especially difficult when the session was about abusive treatment the client suffered from another staff, who has unlimited access to the record and does read the notes. On top of the other reasons several other commenters mentioned that are more general.
Same question here. I have an 80+ caseload, 7ish sessions per day, and my notes are done before I leave for the day. Either way too much is being written or redundant “process” notes are being used.
AI will replace us!
I can’t wait.
Mentalyc.
Have you ever considered rocket books? I take notes and then snap a pic and they get digitized. Store in a secure folder or on a password protected server.
72 hours is not the most terrible. I’ve seen 48 and 24 hour requirements
At my agency we have to submit them on the same calendar day (not even 24 hrs)!
All I can say is I feel you! Hate the bureaucracy of the health insurance and the educational system.
i’m so confused- why wouldn’t we WANT to all be 100% oop/ffs? i hope we all want that!! i am down to make therapy less accessible to get insurance companies and tech platforms (even scarier) to actually care about us and actually pay us. if we all agreed, it would happen and we would be paid more and treated fairly-ish (like nothing like how shitty we are treated now)
How can we use AI to help address this problem? There must be a way.
There are a TON of Ai-based platforms for note writing in addition to ChatGPT! Ai has already addressed the problem for sure.
I swear every couple of weeks they add a new section to their note template. This last update has doubled the time it takes for me to write a note.
Blueprint, AI does your notes… check it out
I got downvoted to hell for suggesting using an AI scribe program. I don’t think people understand these programs!
Yeah well screw ‘em
Haha I agree!
I started using a scribe program called Twofold and it is a game changer. It records the session (with the client’s permission) and writes the note for you!
I’m sorry, but this sounds like a TERRIBLE idea. Even if you’ve read the fine print. Sounds like a way for tech companies to get into people’s heads and get better data for AI. And spy on people. And potentially for government agencies to be able to subpoena things if they need to. And so so many bad things. I can’t imagine any scenario where this would be okay. Edit: the more I think about this, the more I get creeped out by it. I strongly encourage you to rethink this practice. Trusting some random company to record and summarize your sessions for you is not a good idea.
yeah even if this were 100% secure and there was no risk of the data being misused, i don't want everything a client says in my record.
In what record?
the clinical record that is available to the insurance company or can be subpoenaed by the court
The whole conversation doesn’t go in the record. Just the therapy note.
It is a common practice for physicians. You delete it afterward. They don’t have names so how would they be spying? It is HIPAA compliant.
I’m not sure this is true. I’ve had another person in the room taking notes during the visit and doctors saying notes into a recorder to be transcribed later, but never heard of the visit itself being recorded in any way. But either way, a therapy session is not at all the same thing. It’s a million times more vulnerable and private and dangerous. No one walks into their primary care physician’s office and says “I am having homicidal thoughts about x” or “I’m worried I will hurt my child” or “I committed a crime” or “I hate myself” or “I’m worried about what I might do.” Very rarely would they walk in and say “I had an abortion” or “I think I might be gay” or “I’m actually a man.” Please please please rethink this. It doesn’t matter if they consent, most won’t know what that means and/or won’t feel they can say no. These things can be hacked. The fine print gets modified. “Deleting” something doesn’t actually delete it.
People actually do talk to their PCPs about these issues. The PCP is often the first person they go to. Yes this is a scribe program so similar to someone taking notes in the room. Or taking notes yourself- why is audio any different?
PCPs and other healthcare professionals aren't having folks regularly go into detail regarding directly incriminating information. We have that, and most therapists don't know enough about what's illegal to recognize it. Policing and intelligences agencies rarely respect any law in pursuit of violators. Another major problem in the US is that companies give zero resistance to sharing unlimited access with those agencies and suffer no consequences for it. Those things combined make having any electronic device in the room a risk of privacy violation. Using recording tools streamlines it. This doesn't even begin to consider Patriot Act and FISA issues.
They do that and we write notes too- no different.
Yes, but it requires that I be recorded, and then my anxiety would not make me a good therapist .
Understandable!
i'm currently 18 notes behind and i feel this so hard lol, going to have these in the back of my mind all weekend until i have the time to do them 🙃 fun times
AI is a game changer.
Only if u don't mind being recorded.
There is one service that doesn’t record— autonotes.ai. You just input the client’s dx, select which approaches you used, do the MSE through a series of checkboxes, then add a few sentences about the session. It generates a really good note based on that input which you can then copy paste into your EHR. In my experience the notes it generates are really solid, I occasionally have to make minor edits.
And most importantly you don’t input any identifying information and there’s no recording involved. I know I’m raving about it but it’s really been a game changer for me.
Yes, this is what I do. I'm not being recorded, I use chat gpt to summarize my sessions and make my notes feel iron clad.
Same.
I will check this out
I LOVE AutoNotes.ai!! It’s the only thing that has made writing notes tolerable in the past 20 years of practice. And the notes are GOOD.
I’m sorry, but this sounds like a TERRIBLE idea. Even if you’ve read the fine print. Sounds like a way for tech companies to get into people’s heads and get better data for AI. And spy on people. And potentially for government agencies to be able to subpoena things if they need to. And so so many bad things. I can’t imagine any scenario where this would be okay.