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09Dec

Part 2 of the “S” in the “STEPs” to Taking Progress Notes: SYMPTOMS

This is the second 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 last week?  (Please refer to previous blog post, “The ‘S’ in the ‘STEPs’ to Taking Progress Notes: SUBJECT.”)  Last week, information regarding the case study of Samantha was shared.  What is verbally shared in sessions is, without a doubt, very important.  As counselors, observations regarding the non-verbal communication of clients are imperative as well.  When using the STEPs method, the “S” also stands for “SYMPTOMS”, and this part of the STEPs is broken down into four areas:  emotional, behavioral, cognitive and physical.

Think back to the case study about Samantha.  Emotional symptoms refer to what is observed about how the client is feeling both during the session and what the client reports she or he feels outside of the session.  For Samantha, observations about her may include anxiety (about her in-laws coming to visit), discontent (given she does not see her husband often and is now talking to a former boyfriend via Facebook), inadequate (given what she reports about her in-laws, how she feels around the women in her neighborhood, and disciplining her children), guilty (regarding her decision to put church “on the back burner”), irritated or frustrated (with her husband and her children), and she reports being overwhelmed (given all that she reports in the session).

Behavioral symptoms are non-verbal expressions the client either displays during the session or discloses during the course of the therapy.  Behavior is often the expression of what one is experiencing on an emotional level; for example, anger may be exhibited with a loud voice and agitation.  During the session with Samantha, she may have minimal eye contact when talking about the incident with her children in the grocery story.  She may have shown agitation by jiggling her foot when she talked about her husband coming from a wealthy family.  It seems she is engaging in some risk-taking behaviors by getting involved with a former boyfriend.

Observing your client’s thought process is also important as one’s thoughts can often lead to behaviors that can either be helpful or destructive.  These cognitive symptoms can be exhibited by anxious thoughts, confusion, difficulty making decisions, racing thoughts, and tangential thoughts.  Samantha revealed anxious thoughts about her in-laws, difficulty making decisions about attending church, negative thoughts about her parenting skills, and potentially poor judgment regarding her communication with her former boyfriend as this may lead to future marital issues.

Physical symptoms refer to the physical health conditions that the client reports during the session as well as the actual physical appearance of the client.  Given the fact that there is a strong connection between the mind and the body, physical symptoms are important to ascertain as these can provide the counselor with additional indications as to the client’s level of disturbance.  Noting how the client presents physically may be a key indication of how the client is functioning as well, but it is also useful to see if the well-groomed client is “masking” the true internal turmoil and emotional chaos she or he is experiencing.  Although last week’s case study did not share information about Samantha’s physical appearance or physical symptoms, it would be important to inquire about her self-care habits, how she is sleeping, and her eating habits given the issues she shared during the last session.  It is also important to note if she looks as tired as she did state that she is “exhausted” or does she seem to care about her appearance given that she alluded to feeling “not good enough”.

Counselors needs to monitor all of the SYMPTOMS – emotional, behavioral, cognitive and physical – and see how these either decrease, increase or manifest over the course of therapy.  These symptoms are key indications of the type of diagnosis a client receives as well as signs as to how the client is functioning outside of the therapy sessions.  A decrease in the negative symptoms indicate that the client is improving, and a rise in positive symptoms show that counseling is helping and that counseling goals are being met.

This brings us to the progress note you would write.  For the SYMPTOMS section of the STEPs method, you would focus on the four areas of emotional, behavioral, cognitive and physical symptoms as described above.  The STEPs downloadable, “offline” forms (https://www.stepnotesinc.com/Store) provide check boxes you can select for the different symptom areas as well as an area to write in additional information, as illustrated with the Samantha case study.

This is an example of how to use the second part of the “S” in the STEPs format for taking progress notes.  Stay tuned for the fourth blog in this series which will discuss the “T” in the STEPs method – therapy tools and interventions. The same case study of Samantha will continue to be used to show the various STEPs of the progress note format.

If you want to find out more, please feel free to visit www.stepnotesinc.com to view the downloadable forms that provide the format for progress notes using the STEPs method.  Once purchased, you can use the offline forms as often as you like for your progress notes.  You can also read more about STEPs in “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/

 

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