I Hate Therapy Notes! (Let's Talk AI & Therapy Notes)

AI Therapy Notes, AI Progress Notes, AI clinical Notes… searches are exploding for these terms as AI Therapy Notes generator companies are coming out of the woodwork. We feel like we get an email from a new AI therapy note generator every week lately!

So, what is happening, and how does an ethical therapist who deeply cares about their clients make sense of it all? And, why is this SUCH a big deal? Well, we think this reddit post from 2022 that popped up when we typed in “I hate therapy notes” perfectly sums it up:

“I HATE notes!! How do you get through it? As a therapist, I think I’m pretty solid. I have a great retention rate, very little if any no-shows, client-to-client referrals and all that good stuff. On paper…I feel like the absolute worst. I find it so hard to put down on paper what was covered and it’s just so painful for whatever reason. I’ve tried using the treatment planner and progress notes planner books but it hasn’t quite clicked. Does anyone have a recommendation on any software/site/templates that have worked well for you? Thanks in advance!!”

Side note: We have a free CE AI Therapy Notes training upcoming August 27th led by therapy documentation expert Dr. Maelisa McCaffrey that you can register for here where we will be diving deep into this topic.

Progress Notes- how did we get here?

In graduate school many of us had limited training on how to do a progress note with a few hours at MOST about the difference between a SOAP note, DAP, etc. Many of us were told that we’d learn the specifics about how we were meant to document on the job in practicums and internships. And then we got there and found it was the clueless being lead by the helpless. It seemed like the only person who had any expertise regarding notes was the person trying to make sure that insurance based services got reimbursed. So, either you worked at a place where notes were seldom, if ever, looked at or you worked somewhere where the notes were all about reimbursement. Neither feels very good.

Miranda remembers having to ask her clinical supervisor to please review her documentation in her files to help her learn how to do notes. And, as Miranda recalls it, her clinical supervisor was pretty surprised at the ask. They had never done that in clinical supervision before and they weren’t particularly confident about progress notes either. However, just having the conversations as part of the clinical supervision led both people to feeling more confident.

When is the last time someone looked at your therapy notes?

The odds are, the only time you have someone looking at your clinical documentation is when you are feeling judged. Insurance reviews, subpoenas, quality assurance reviews from your boss. It is really easy to start to see therapy notes and anyone reviewing them as the enemy, and something associated with anxiety and stress. And yet, therapy notes should be a beautiful thing! They should be something your client could read at the time of graduation and see a timeline of their beautiful transformation, what worked for them, what didn’t, with a clear path to finding healing in the future if things ever needed attention again. Kelly likes to think of them as a love letter from the therapist to client, sharing what they saw, neither cold or shaming, removed or solely diagnostic, but helpful to the client.

Now add in electronic health records

Electronic health records were supposed to make the documentation easier. And, for some, it did. But, for many it actually created MORE documentation requirements. Miranda provided clinical supervision for a primary care clinic where the computers were so slow and there were so many screens and boxes to tick that it literally took MORE time to do the documentation than the therapists were able to spend with their clients. That is NOT ok! Documentation should not ever become the focus of the time suck. Getting great outcomes with our clients should always be the #1 priority!

Do You Know You Are Getting Great Outcomes and Do Your Clinical Notes Show That?

Again, many of us if we were taught to track clinical outcomes in our training were taught in a way that was unsustainable and often not client-centered. The outcomes we have been asked to track have not always really related to what was REALLY happening in therapy. How do we put the magic and art of therapy into words? How do we recall the amazing quotes said by our clients about the benefits of therapy while staying completely present in the room with them and not spending our time typing looking at a computer screen?

Enter AI Therapy Note Software

Now suddenly we can have a scribe to listen intently to what is happening from both you and your client and document the interventions, the outcomes, and do so in a way that meets both legal requirements and also reimbursement requirements. This could be great!

But, like every new technology there are a lot of things to navigate:

• A lot of these companies are NOT run by therapists and they don’t really understand the ethical obligations.
• Software companies are claiming to be HIPAA compliant or be HIPAA consistent when they aren’t really.
• Therapists don’t understand the technical aspects of HIPAA well enough to discern who to trust.
• AI Therapy Notes still require therapists to be able to read and discern what a good therapy note should look like and make adjustments.
• AI Therapy Notes can sometimes just give you wrong or bad outputs that are NOT useable- you can’t just set it and forget it.
• There are SO many options to sort through and navigate and it becomes just another thing that we have to track.

But, let’s not forget some of the beautiful things that a well-designed technology like this could do:

• Allow therapists to spend more time with clients doing what they love.
• Create better documentation records that are more beneficial to the client if the therapist dies, if they are transferred, etc.
• Reduce clawback from insurance companies ensuring therapists get paid for the hard work they did.
• Decrease wait times for reimbursement when documentation is done more quickly and insurance submissions can be done more quickly.
• Reduce overall denials from insurance.
• Improve billing practices and billing coding. We imagine these software options will eventually have add-ons to help with billing complex sessions and codes.
• Create more rest between sessions for therapists to be fresh and ready for their next client.
• And so much more!

What are things you need to look for in a AI Therapy Note Generator?

• They need to be HIPAA consistent and you need to understand what that is. That goes well beyond just them signing a Business Associate Agreement (BAA). That does NOT exclude your responsibility.
• You need to be able to get client permission or agreement. You’ll never have that as 100% agreement, so you still need to understand how to quickly, efficiently, and effectively write therapy notes.
• You need to make sure your documentation is truly specific to the client. You cannot copy and paste the same note into every session for every client. Client quotes, specific updates, etc. are integral to great AI clinical notes

Let’s talk about amazing resources when checking out different AI Therapy notes tools. Expert therapy notes trainer Dr. Maelisa McCaffrey has been doing online reviews of each AI Therapy Note options as they are coming out. These softwares are changing rapidly so it can be VERY hard to keep up with. This AI Therapy Notes Playlist on YouTube is gold and includes reviews of many options.

We hope you will join us for our free live training with Dr. McCaffrey August of 2024. Click to learn more and register for the free AI Therapy Notes Training We’ll be offering a time-limited recording and she provides a handy-dandy worksheet with updated reviews and sample progress notes from each of the software options.

Have questions about AI Therapy Notes? Have an option you love? Share it in the comments below!