This is the fifth and last in a series of five blog posts designed to inform counselors about the STEPs method for taking progress notes – a method that is systematic, efficient and effective.
The fourth step in the STEPs format for progress notes is the “P” – the PLAN section of the progress note. The “plan” establishes continuity between sessions and context for upcoming sessions.
Counselors want to make sure they have a “plan” so that they can refer back to their notes before they see their clients again and be reminded of what they need to focus upon for the next session. The “plan” refers to the short and long-term goals developed during the course of the therapy, with the central objective being the improvement of the client’s well-being. Plans can include homework, interventions, and goals. Plans can also include topics or other details that were not discussed during a session or statements the client made during a session that need further follow-up. Counselors should develop plans that ensure clients are striving towards and meeting short and long-term goals in a focused manner. Plans will vary from counselor to counselor, depending on the counseling approach and style. For example, a cognitive-behavioral therapist may use different types of homework assignments than those of the practitioner who employs narrative counseling techniques.
Thinking back to the case study of Samantha (see earlier blog post from November 30, 2015 at https://drrhondasutton.wordpress.com/2015/11/30/the-s-in-the-steps-to-taking-progress-notes-the-subject/), it will be important to identify homework assignments that focus on building her support system, improving her communication skills with her husband, and learning more effective parenting skills to use with her children. Other goals may focus on increasing her self-esteem, engaging in activities that diminish her depressive symptoms, and using tools to cope with anxiety. In the “Plan” portion of the STEPnotes, the Samantha’s counselor may use statements such as:
- Samantha will utilize assertive communication tools she has learned in counseling to express to her husband her desire to spend more time with him and to have him be more involved in the raising of their children.
- Samantha will integrate parenting skills, discussed in counseling, to more effectively manage the discipline of her sons.
- Samantha will practice mindfulness techniques to cope with anxiety.
- Samantha will decrease depressive symptoms through exercise and improving her sleep schedule.
- Samantha will increase her support system by going to church, getting involved in volunteer activities there, and joining the book club in her neighborhood.
More information about the “Plan” portion of the STEPnote as well as suggestions for how to write goals are available in “The Counselor’s STEPs for Progress Notes: A Guide to Clinical Language and Documentation available on Amazon at: http://www.amazon.com/Counselors-STEPs-Progress-Notes-Documentation/dp/1514643588/. The STEPnotes downloadable forms, which can be stored on your computer or the PDF can be uploaded into your EHR, provide sentence stems to outline goals in the “Plan” portion of the progress note. Examples of sentence stems are “client will change”; “client will decrease”; “client will exhibit” and “client will implement.” The PDF form offers over 30 sentence stems for this part of the progress note. These forms are available for mental health, school and career counselors and are at: https://www.stepnotesinc.com/PDF-Forms. PDF forms for both adult and adolescent/child intakes are also offered.
The STEPs were created to help counselors have a structured and professional way to document their work with their clients. The format offers a streamlined method to write progress notes by detailing the subject, symptoms, therapeutic tools and interventions, evaluation and plans for clients. Those who use the STEPs can keep better track of the progress of their clients, identify what is and is not working well in therapy, and be able to review their notes quickly before each session so that they can be better prepared to work with their clients. STEPnotesTM provides the organized format for progress notes which indicates to both mental health professionals and those outside of the counseling field the importance and the value in the work undertaken by counselors, therapists, social workers and other mental health practitioners.