This is the third 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.
Remember Samantha from the November 30th blog post? This fictional client was anxious, overwhelmed, depressed, lacking in self-esteem and making poor choices. The first part of “STEPs” – SUBJECT(s) and SYMPTOMS – focuses exclusively on the client. The “T” in the STEPs method focuses on what you, the counselor, do during the course of the session. “T” refers to the therapeutic tools you incorporate to help the client move towards her or his goals and improved levels of functioning.
When using the STEPs format for progress notes, you first will choose the types of therapeutic approaches you use with the client. In the case of Samantha, you may want to choose cognitive-behavioral therapy to deal with her feelings of depression and anxiety, reality therapy to address the issues she is having with her husband and with re-engaging with a former boyfriend, and person-centered therapy to continue to show nonjudgment, to build rapport and to demonstrate unconditional positive regard.
In addition to the therapeutic approaches, this part of the note is very important as it breaks down more specifically what you, the counselor, did during the therapy session. Action verbs are used to start sentences to show the counseling skills and techniques you utilized to assist the client. Using the case study of Samantha, you may write sentences such as:
Acknowledged the many concerns and feelings Samantha was currently experiencing
Addressed Samantha’s concerns about the upcoming visit with her in-laws
Asked Samantha the “miracle question” regarding her marriage
Demonstrated ways to improve communication with husband using assertive techniques
Evaluated realistic goals regarding the online communications with the ex-boyfriend
Explored Samantha’s issues with her self-esteem and when negative self-talk started
Guided Samantha through a role play of disciplinary parenting techniques to use with her sons
Identified two goals for Samantha to pursue in the upcoming week to improve functioning
Reflected on strengths Samantha has used recently with moving to a new place, making adjustments
Reframed Samantha’s negative self-talk about not being “good enough” for husband’s family
The “T” section in STEPnotes shows what you have done and further helps to establish what is and is not working in therapy. (We will talk more about evaluating the counseling approaches and goals in the next two upcoming blog posts). Keep in mind that this section also shows third parties the work you have done as a counselor; these third parties may be insurance companies or legal entities should they request a copy of your progress notes. What is always important to keep in mind is that you keep your progress notes objective and factual. These are records that may be open for third party review, so you will want to document a neutral account of what occurred during the therapy session.
Should you want more suggestions for action words or more details regarding the STEPs for taking progress notes, read “The Counselor’s STEPs for Progress Notes: A Guide to Clinical Language and Documentation” available at: http://www.amazon.com/Counselors-STEPs-Progress-Notes-Documentation/dp/1514643588/. The book contains over 60 action verbs to help counselors write sentences that clearly document the counseling skills they used with the client. If you want to be more organized with your progress note format, consider using the downloadable, “offline” forms at www.stepnotesinc.com that can be uploaded as PDFs to your existing EHR system or stored on a secured computer. Once purchased, you can use the offline forms as often as you like for your progress notes (and intake note formats for both adults and adolescent/children are also available as downloadable forms).
Stay tuned for more information on the “E” and the “P” parts of the STEPs, using the Samantha case study, so that you can use the STEPs for your progress note needs.