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30Nov

The “S” in the “STEPs” to Taking Progress Notes: The SUBJECT

This is the first 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.

Counselors, have you ever had a session like this (and please note that this is a fictional case study and any resemblance to any living persons is fully coincidental):

Samantha comes in for her third session with you, the counselor.  During her intake four weeks ago she shared that her goal for counseling was to communicate better with her husband.  Your goal is to follow up to see if the communication suggestions you both have discussed have been implemented. 

Samantha’s husband travels a lot, and she shares with you that they are getting along better, but she is a little anxious about the upcoming visit that is scheduled with her in-laws as she has never felt “good enough” for her husband given the fact he is from such a wealthy, prestigious family.  Samantha said that she has struggled with self-esteem for awhile; what has helped her in the past is her belief in God and her faith…however,  Samantha goes on to state that she has been having some spiritual issues lately as she and her sons have not been to church since they were baptized. 

She is often tired (although the boys go to preschool for four hours a day), and she does not like going without her husband who has said that when he is home on the weekends, he just wants to “kick back and relax.”  Thus, church has been put “on the back burner” and Samantha feels guilty as she was raised in a household where her family went to church every Sunday. 

Her mother often asks her if she is going to church, and Samantha admits there are times when she does not tell her mother the truth about her church attendance.  Samantha feels guilty about this and wonders if she could build a support system at church, but she has been trying something else in terms of building friendships since she and her husband just moved to the area five months ago.

Samantha next reveals that she has tried to be more active in her neighborhood as there are a number of stay-at-home mothers who live nearby, but she still feels “left out.”  These women have lived in the neighborhood a lot longer than she has, and Samantha stated that she is trying to “find her place” with them and would like to have some playdates but…then  Samantha shares that she is embarrassed by the fact that her sons seem to be “going through a stage” as they do not listen to her and are very difficult to discipline when they are out in public together.  Samantha discusses a recent episode in the grocery store where the boys kept pulling items off the shelves and the manager had to ask her to pay for the box of cereal that the boys had torn open while she was looking at other items on her list. 

Parenting is exhausting work for her, and she is “tired of doing it alone.”  In the remaining five minutes left in the session, Samantha disclosed that she has recently re-engaged in conversations with the man she thought she was in love with when she attended college.  She found him on Facebook, reached out to him, and they “talk” daily now online about their marriages, their children, and their college days.  After this forty-five minute session, you – the counselor – may wonder, “what was the focus of THAT session?!” given that Samantha talked about a variety of issues and bounced from topic to topic.

This brings us to the progress note you would write, and where to begin.  Using the STEPs method – subject/symptoms, therapy tools, evaluation and plan – you would first focus on the SUBJECT(s) of the session.  The STEPs forms (available at https://www.stepnotesinc.com/Store) provide check boxes you can select for the subjects.  With the case scenario above, subjects would include:  family problemslack of fulfillmentmarital discordparenting issuesrelationship problemsself-esteem issuesspirituality.  As the counselor, you may want to add more descriptive terms in the box provide under the check boxes such as: Client feels lonely within her parenting role as husband travels a great deal and most of the childcare/discipline is her responsibility.  Client is experiencing a sense of loneliness, lack of fulfillment as evidenced by her recent contact with a college boyfriend via Facebook.  Client is struggling with parenting issues and discipline of her twin boys who are four years of age.  Client has attended church in the past and has gotten support from her faith; however, she has not established a church community here as she and her family moved here five months ago.  Client expresses guilt over not attending church.  Client lacks a support system and is trying to build one with other mothers in her neighborhood but struggles with this as she is the newcomer and the other mothers have known each other for some time.  Upcoming visit with her in-laws is causing client some anxiety given her perception of how she thinks they view her and her current lack of self-esteem.

This is an example of how to use part one of the “S” in the STEPs format for taking progress notes.  Stay tuned for the second part of the “S” – symptoms – as nothing these will assist you in your work with noting your client’s progress and engagement in therapy (i.e., blog post 3 of 5).  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.  There are downloadable forms that provide the format for progress notes using the STEPs method.  Once purchased, you can use this offline form 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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