As the end of 2015 approaches, it may be time to start thinking about what you want to improve upon for 2016 . Part of that improvement may mean “be more organized” which happens to be #6 on a list of the top ten New Year’s Resolutions.
Organization for your clinical documentation means more than just having your files neat and accessible. Ask yourself: How do you organize your thoughts around your counseling sessions? How do you conceptualize the therapeutic work you undertake with your clients? These questions are important because being organized with documentation starts long before you start to write the note about the counseling session. Thinking about the various aspects of the session such as what the client discussed, how the client presented, what the client reported, the client’s response to your questions and suggestions, what both the client and you verbally and nonverbally shared, and how all of these different activities within the counseling hour align with the therapy that is occurring is imperative to “doing counseling”. There is a method that can help, and I will offer a breakdown of this method through five blog posts that will be produced between now and the end of 2015 so that you can get both your files and your approach to progress notes prepared for the upcoming year.
The system is known as “STEPs” and it was developed due to a number of concerns expressed by supervisees who had not been taught a reflective, consistent, and orderly way to take progress notes. Each of the STEPs in this method provide a framework for how therapists can reflect and record the work they have done with their clients so that progress is noted, problems are identified, patterns are recognized, and documentation is clear. The STEPs assist clinicians in formulating what is working with their clients and what the plans need to be for the future. The goal of the STEPs method is to help counselors have a systematic, organized and efficient way to write their progress notes so that they (and others who may review their progress notes) can see the impact of therapy with their clients.
So, are you are ready to learn the STEPs to taking progress notes? If so, be on the lookout for the next blog: “The ‘S’ in STEPs: The Subject of the Session”.
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.