In my interaction with therapists as a mentor and supervisor, I’ve learned that one of the main struggles therapists face is having too much work and not enough time. Many therapists find themselves overwhelmed by documentation responsibilities, in particular; this includes completing client notes, referrals, billing, treatment plans, etc.
In today’s post, I offer several strategies for keeping up with paperwork, so that you can stay on track and avoid the stress of falling behind.
1 | Develop a session checklist
Create a list of all tasks that must be finished for every session. Aim for getting all session tasks completed within the session time, or within the day’s working hours. Make sure the checklist is easily accessible, so that you can check off items and know they’re complete by the end of the day. (For a free session checklist, see the end or this post).
2 | Learn your state's documentation laws and rules
Every state’s documentation standards are different. Make sure you are familiar with your state’s documentation expectations, and create systems and templates to keep track of required information. For example, you can:
- keep a spreadsheet or paper log for payment information
- create a client note template that incorporates checklists and short answers (to keep things short and simple)
- type repetitive phrases into your paperwork, so that you don't have to re-rewrite them every time you fill-out the same form
Being familiar with your state's documentation allows you to distill that information into simple templates that work best for you and your work environment.
3 | Complete session notes with clients
Let clients know that you prefer to write notes collaboratively. Get their views on the process. If they have no objections, dedicate the last 15 minutes (or so) of the session to completing the session note with your clients. This is an easy way to incorporate client quotes and language into documentation, give clients a say in their medical record, and ensure that your note is complete within the allotted session time.
4| Schedule note writing time
Set a goal for paperwork completion; for example, you can decide if you want to be caught-up within the day or within the week. I don't recommend a goal longer than one week, because that can lead to ethical violations and mounting paperwork. Once you set the goal, there are a few additional steps you can take for accountability:
- Have a specific plan for the time you have available when clients no-show, cancel, or arrive late. This is a great time to complete specific notes, billing, or phone calls.
- Batch time. Schedule blocks of time every week dedicated to completing one task, for example: billing, notes, or scheduling. The key is to have one task in mind for a scheduled block of time.
- Allot more than the typical 10 minutes between client sessions (if your work environment allows). This is built-in time within your workday that can help you stay caught up
5| Set phone hours
Setting hours for when you take and make phone calls limits out-of-session communication with clients, which can help you keep better track of phone conversations. If you set phone hours for times when you're in the office, or in work mode, then you are easily able to document in the moment. Taking and making phone calls at all hours can easily create a back log of phone notes. To avoid this, stick to specific times for phone availability.
Today, I've covered 5 steps for keeping up with therapy paperwork. Hopefully these can help you get caught up and stay caught up with therapy documentation! If you have questions about your specific situation regarding paperwork, get in touch.
Free Session Task List
I've put together a simple session task list to help you stay on track with client paperwork. It can be used as is, or as an idea generator to create your own list. You can download it here:
- What is your #1 barrier to completing paperwork on time?
- Which of these strategies would you like to implement right now?