Writing your notes during the session
This must be the topic that I discuss with all my coaching clients, hear about from professional workmates and get asked during Power Calls. Every. Week. I am keen to share my thoughts on this topic, step aside which I get ready on my soapbox. Session notes are exactly that, they are written during the session preferably collaboratively with the client and carer.
In my opinion, the session note captures the progress towards goals, activity between sessions, tasks done during the session and rationale, explanations and suggestions. We verbally discuss this with the client, so pausing to record this in writing is the next step. I like to include the child’s voice in things they say and ideas they have are lovely to acknowledge.
Emailing the session notes to clients is value adding to their experience of working with you and when educators and other team members are cc/d this encourages great team building and strong marketing for your business.
Please use technology. If you value your personal time and that of the paid time of your clinical and admin team, then type in your notes directly into your practice management software. During the session. The typical private practice can’t tolerate the cost of admin or clinicians re-typing notes, scanning notes and essentially double handling in any shape or form. If it suits, use photos and video to capture and supplement the session notes, the technology is readily available to do so.
It is professional to write notes during the session. I have personally done so for over 25 years as have my teams over the years. Boom. Yes, it takes practice and confidence to steer the conversation, summarize and write short effective notes, ideas and actions. But it can be done. In private practice efficiency is king. Writing notes for hours in the evening seriously dilutes your profitability, erodes your personal time for fun, family and friends and fast tracks burn out. How much personal time do you donate to writing up session notes?
Structure Helps Routine
A template helps organise your thinking and continues to develop an internal thinking and note writing superstructure. Templates can be loaded into your practice management software. Follow the structure but with a growth mindset. Be ready to change and improve it as required.
Different clients mean different notes. Sometimes it will be harder to write up the session notes during the session, I get that. However, the notes can certainly be started and major points noted. As many of you know I am not a fan of 30-minute sessions, it is challenging to complete notes in this short time frame, but many clinicians are succeeding. It is OK to step back from delivering hands-on therapy for a few minutes to collaboratively capture the session and its outcomes.
Session notes are probably too long. A well-planned session delivered with succinct conversation makes it very easy to write a powerful summary with dot points, actions and next session ideas. Allied health professionals often write way too much and wonder why their documents aren’t read. A 30-minute session with 15 minutes to write the note is probably not profitable.
There you have it, my session notes rant is over. I hope that this gets you thinking. Ideally, you could take this challenging topic to your teams for discussion and activation in your practice.