On Monday, Brenda Bomgardner, a student intern at Regis University, wrote in asking for efficient ways to record her clinical notes. This is the first of five posts to help you sort through your choices for clinical note taking.
You can be reasonably confident that if you are working in an agency, the content and format for your clinical notes are already stipulated. However, for those of you entering private practice, you have more leeway in deciding what your client notes, often called “progress notes“, will look like.
All mental health disciplines require documentation of your clinical work. Although the required content for that documentation varies from discipline to discipline and from jurisdiction to jurisdiction, there are general categories of information that are required for you to keep in your records. These categories typically include contact information, your client’s presenting problem, your assessment, treatment and plan.
In addition to free form notes, there are at least four common ways to standardize and record this information. They are:
Next week, I’ll begin by showing you how to take a SOAP Note. By the end of this series, you will have enough information to decide how best to keep your own clinical notes.
Do you know of other formats that you like to use? If so, please share them with us here so that we may all learn from you!