Individual and Group Progress Noting Tips for Success

Notes have to be done for reimbursement. I find that of the documents in a chart, notes tend to be the least consistent in terms of information and quality. Here are two suggestions to make sure noting gets done EVERY time.

End the clinical session after 45 minutes and spend the last 15 minutes with the client writing the note together. We review what was discussed, progress that was made on goals, goals/assignments for the next week and any referrals that need to be contacted. This helps the client see their progress,see how things are connected, reminds them of what needs to be done over the next week and gets the noting done before they even leave your office :)

When I do groups, each client has a notebook. I pass out the notebook at the end of group and clients fill out the following questions for that day

Date: ______

1. What was the most important thing you got out of group today?

2. How does today's topic relate to your treatment plan?

3. What else, if anything, would you like to have covered or done in group to help you with your recovery?

4. On a scale of 1-4, what is your average mood today? (1-miserable, 2-blue/depressed 3-Content 4-Happy)

5. When is your next appointment with your primary counselor?

Obviously that usually only takes up about 1/3 of a page, which is why I use a notebook to avoid wasting paper. The notebook is stored in their clinical file.

This does not replace the clinical group note, but I really try hard to keep clients involved in the process and it gives auditors things to look at "In the client's own words."