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!
Tamara, thank you for providing the variety of choices for client progress notes. I appreciate the “how to use” for each format helpful.
I will try each format and pick the one that works best for me.
Glad to be of help!
The regulation is spelled HIPAA, with two AA’s, not HIPPA, with two PP’s. Health Insurance Portability and Accountability Act.
Just FYI.
Oops! Thanks so much, Dolores, for taking time to correct my mistake! You are right, of course! I’ve corrected it!
Hope you’ll drop back in often to join the conversation as we build our community here at Private Practice from the Inside Out!
These are very similar to the type of notes I have been taught to do in my community mental health clinic [which is contracted with Dept of Mental Health]. We do notes in what’s called GIRP format:
G – Goal
I – Intervention
R – Response [from the client]
P – Plan
Just wanted to share this! The SOAP notes are similiar!
Mercedes! Thank you so much for taking time to add this format! It’s another excellent addition!
Mercedes, Thank you fro another option. Also, I believe GIRP would work well for coaching too. Bb
Thanks for this post. It’s nice to have this resource available!
Hi, Syras and welcome to Private Practice from the Inside Out! It’s good to have you among the Manitobans who hang out here! I checked out your website and notice that you are getting ready to hang out your shingle this Fall! Congrats to you! Looking forward to networking with you, learning from you, and sharing what I know, too, about building a strong and vibrant private practice! I hope you will drop back in often to chat!
Mercedes, I really like the style of notes(GIRP) that you commented about. Ive been using SOAP notes and they are pretty similar, but I like GIRP a little better. I’m gonna have to try them out.
Tiffany
Tiffany, that’s absolutely the BEST thing about Private Practice from the Inside Out! This online community is great about adding to the resources that are already here and they are great about taking the time to say “thank you,” too!
Hi Tamara,
I’ve been exploring your website for the last 6 mos at least, and finally decided to chime in on something. I work 30 hrs a week as a mental health counselor in a university setting, and have just started a small (very small!) private practice on the side. In both cases, I’m able to use a format of note-taking that fits my conceptualization of the session: Presentation/MSE (observable presentation, reported mood, affect, SI/HI, and other typical aspects of Mental Status Exam), Discussion/Interventions and Plan. Unfortunately, it doesn’t provide a cool acronym! I still struggle with how much info to include – I want to remember certain details from session to session that may seem like a bit TMI, but I also don’t want to keep separate process notes. Anyway, it works for me. Thanks for your awesome website! You have unknowingly held my hand as I’ve branched into the realm of private practice.
Shaney McCoy, CMHC
Ogden, UT
Shaney McCoy! Welcome to Private Practice from the Inside Out! And, thank you for hanging out with me here and for taking time to share your not-taking strategy! (I’m thinking this is the PD/IP format🙂 otherwise known as the Shaney McCoy Method!”) It’s so helpful to have all these different choices in one place so that new therapists can see that there are multiple right ways . . . including their own methods. It’s not a message that most of us received when we were in grad school or just starting out so I’m happy to collect them all right here. And, who knows . . . if /when I get around to putting a new list together, I’ll be more than happy to include the Shane McCoy Method along with the rest!:)
Shaney, I’m glad you finally decided to speak up. If / when you put up a website for your private practice, feel free to drop back in and let me know. I’ll be happy to link your comment to it and push a little online traffic back your way!
Thx for the helpful info. Our school-based staff is required to use online record keeping, but we still keep pertinent notes in personal work files. Will look into your resources. Karen
Hi, Karen! I hope you find something of use there and will be back often to join the conversations here at Private Practice from the Inside Out!
Hello,
I do follow your posting. I am new to private practice. I find myself lagging behind and I have tried about three software and find they really do not ft me style.
Do you use an EHR software for your notes?
Thank you
Jumoke
Hi, Jumokw! Welcome to Private Practice from the Inside Out!
I do not use electronic health records for my documentation and do not recommend that those who are new to private practice start off with using EHR for a couple of reasons . . . .
New clinicians rarely know what they want for their long term use.
EHR can be pricey and may be a good investment but in the beginning of a new practice, it’s not where I would recommend putting your money.
The second issue I have with EHR is that new clinicians are often still learning to conceptualize their clients and their needs; I have found that by relying on an EHR to craft your documentation, new clinicians are often delayed in developing that basic skill of case conceptualization.
My recommendation is to give yourself 5 full years to do it “the old fashioned way” with pen and paper records.
At the end of that period, if you still want an electronic health record system, then go for it!
You’ll be a much stronger clinician quicker that way.
But, if you are determined to purchase one, you might want to check out the guru of electronic health records, my friend and colleague Rob Reinhardt, LPCS.
Start by reading his post Affordable Electronic Records (EMR, EHR) for Mental Health Professionals.
Totally agree. Plus if a clinician prefers a particular modality such as DBT, EMDR, ACT, etc., it is useful to custom design a progress notes form.
YES! Thank you so much for saying this! There’s nothing magic about any of the templates here. And, on the other hand, if you have designed one of your own that you would like to share, feel free to send it to me or attach in a comment here. Happy to share your brilliance!
Wow, this is good to know. Thanks for clarifying this. I’m just getting started and thought EHR software was the way to go.
You’re so welcome, Ginger!
Thanks for letting me know it helped!
I hope you’ll be back often to join the conversations here at Private Practice from the Inside Out!
I think it’s important to use a note-taking process that fits your style of personality and therapy. To that point, I found the STEPNotes to be a great fit for me.
In case you want to check it out, here is the link: http://www.stepnotesinc.com/Note-Formats
And, I had not heard of the BASIC SID Notes…will check it out now!
Thanks, Tamara!
Barbara! I love that you’re sharing another style of progress notes because, as you note, it’s so important to find one that is a good fit for you!
Looking forward to trying this one out!
Thank you!
Barbara, I agree it is important to find notes that fit for you. I ended up customizing my notes to fit the modality of my preference – ACT (Acceptance and Commitment Therapy) so that I can track the progress in the six core processes.
The other thing I did to customize my notes was to put two sessions on one page. It helps me track the continuity from one session to the next with any notes about homework.
Ohhhh, nice, Brenda! Feel free to share your customized template right here if you wish!
Hello Brenda,
I’m wondering if you can forward me a copy of your notes template. I’m struggling with keeping progress notes and I use ACT. I would be grateful to have more guidance.
Thanks Danielle
Hi Brenda!
I practice ACT and would LOVE a copy of your template if you are willing to share!
Erin
Erin,
Please contact me for instructions on how to get the ACT form. 720-260-7702
I am a mental health counseling student and really enjoyed your website.
Hi, Ada! Welcome to Private Practice from the Inside Out and thank you for taking time to follow my work! I hope you’ll drop back in often to join the conversations and let me know if you can’t find what you are looking for!
Do you have any GIRP progress note taking samples?
I do not, Emily, but I suspect you can find plenty of examples by simply googling “GIRP progress note samples.”