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Collaborative Documentation: First Start with the SUBJECT

     Recent posts have discussed collaborative documentation – what it is and how to introduce this more efficient method of taking progress notes to your clients.  The next few blog posts will address the “STEP” method for how you actually document the progress notes along with your clients in the collaborative documentation progress.  I will utilize a fictional case study of “Chris” who has a history of anxiety and agoraphobia.  This first post will focus on part 1 of the “S” in the STEPs method.

      As with any therapy session, you need to document what was discussed during that particular time with the client.  Therefore, the first part of the STEP indicates that this is where you document the SUBJECTS the client focused on during the session. 

      Let’s take the case of fictional Chris.  Chris has been seeing you for over eight months, and each session begins with a statement something like, “Well, I left the house once this week to go to the dentist.  I know we talked about getting out three times this week, but it just seemed easier to have the groceries delivered, and I did not need gas.”  As the session progresses, Chris continues to talk about feeling anxious and the thoughts and behaviors associated with the anxiety. 

      What is important to do as a part of the collaborative documentation process is to say to Chris, “Now I want to make sure I capture the most important aspects of our session today, and I first want to check with you about the main topics we discussed.  I heard you share that you remain anxious every time you leave your house.  From what I understood you to say, it seems that this is getting worse, and that your thoughts about something bad happening when you leave home are getting in the way of you going out to take part in regular activities such as grocery shopping, going to your exercise class, and meeting up with friends.  I hear that you feel grateful that you get to work from home, but I also hear that you are becoming less and less likely to go outside your house, resorting to online shopping and grocery store delivery.  It sounds as if your anxiety is increasing.  Did I hear that you left your home only once in the last ten days?”.  

      Making statements such as “I heard you say” and “From what I understood you to say” indicate to the client that:  1) you were listening and “tracking” what the client was disclosing; and 2) gives the client an opportunity to hear their story outside of themselves.  This can be helpful as the client may be able to gain a different perspective on what they shared, and they will also be able to let you, their counselor, know if that if what you understood the SUBJECT of the session to be is in line with what the client was meaning to focus upon during the session.

       As you confirm what you heard and get additional feedback from your client, write down what was shared.  In the case of Chris, the SUBJECT(s) would be anxiety (and possibly social anxiety and depression).  If you are using the STEPnotes method for progress notes (www.stepnotesinc.com), you will already have a list of SUBJECTS that you could check off while you writing out the progress note while working with the client on the note.

The SUBJECT portion of the note focuses on what the client discussed with you during the therapy hour and provides the foundation for how you approach the therapy session.  Did the client talk about being depressed, anxious, frustrated with their partner, overwhelmed by work, unsure of how to discipline their children?  Was the SUBJECT in line with what the client has discussed in previous sessions and, if so, has anything about the SUBJECT changed, or did the client seem to be repeating a pattern or seem stuck?  Keep in mind that if the same subject keeps coming up over and over again in a session with no progress or change being made, then you, as the therapist, need to address this with the client and figure out what needs to be done differently in counseling.  A client who is not making any progress may need a different therapeutic approach or may need to learn other tools to help them make some positive changes.

The next blog will focus on the next part of the “S” STEP for your progress note as well as how you continue to collaboratively document, with the client, the work you both did in the session together.  To get an idea of an idea of other SUBJECT(s) the client could discuss, try out the new online STEPnotes system at https://www.stepnotesinc.com/


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