The STEPnotes Concept | STEPnotes


Why STEPnotes

Why should counselors choose STEPnotes™ for their documentation needs? Counseling is a profession, and we need a professional method for our documentation. STEPnotes™ provides the professional structure and approach for our progress notes given that is was developed by a counselor for counselors.

Dr. Rhonda Sutton, the creator and founder of STEPnotes, is both a licensed professional counselor and a licensed professional counselor supervisor in the state of North Carolina. She herself struggled for many years with her progress notes, being uncertain of how much to write and what to include. She also felt that her work needed to show evidence of professional thought, attention and detail. In addition, many of Dr. Sutton’s former supervisees shared with her their concerns about taking progress notes as they had not been taught in graduate school a way to document their work with clients. Given these concerns, Dr. Sutton developed a structured format for progress notes that she has named “STEPnotes™.” Since the creation of STEPnotes™, Dr. Sutton has written a book and gotten the method trademarked (thus the “™” at the end of STEPnotes). Following is an overview of the “STEPs” for taking progress notes:

The "S"...


The "S" denotes both the verbal and non-verbal communication in the session.


What was the SUBJECT of the session; what did the client discuss or what were the main concerns shared during the session? What SYMPTOMS or behaviors did the client display? SYMPTOMS within STEPnotes™ are categorized by the emotional, behavioral, cognitive and physical symptoms the client either shared or displayed during the session.



The "T"...


The "T" refers to the actual therapy or treatment TOOLS and interventions that you, the counselor or the coach, provided.


This is the part of the session where the counselor documents their work with the client (and this is also the part that is very important in the case of audits by an insurance company or other outside reviewer). Various therapy approaches are provided as choices (such as cognitive-behavioral, existential, etc.). In addition, action verbs are offered as a way for the counselor to indicate the techniques and methods used to guide, assist and support the client during the session.



The "E"...


The "E" is associated with the counselor’s EVALUATION of the client and the client’s progress.


It is important for the counselor to assess how well the client is functioning. In this STEP, the counselor is provided a scale to indicate how well the client is functioning (from “1” which indicates a need for a higher level of care to “10” which indicates that the client is ready to be discharged from treatment or to terminate therapy). In addition, choices as to how engaged the client is with therapy are given so that further evaluation of the client’s willingness to be in counseling can be noted.



The "P"...


The "P" stands for PLAN.


This STEP focuses on the short- and long-term goals for the client. What are the goals for the next session and future sessions?  What action items/plan did the counselor share with the client?  Was any homework assigned? This section is important to review before the next session so that the counselor can check in with the client about any homework assigned and help the client stay on track with his or her goals for treatment.



Documentation is essential to the work of counselors. Having an efficient and effective way to maintain progress helps counselors provide an ethical, thoughtful and structured approach to their work with their clients. It is the goal of STEPnotes™ to provide the way for counselors to note the progress of their clients.