Session documentation and note-taking are things that everyone does differently.
You need to do them, but that doesn’t mean it’s easy or your favourite thing to do. Making sure you can review your clients’ progress is vital to understanding how to provide help, but if you’re not one of those people who can write full paragraphs during a session, you’re probably transcribing them from cramped short-hand at the end of your day. Not to mention storing them, in order, and in good condition. It’s a big chore!
Thankfully, digital note-taking can make your life easier. How?
Here are 10 ways:
1 Customized Note Templates
There are lots of ways to save time using customized note templates. They’ll be available at the click of a button, ensuring you don’t miss any important details. They make note-taking more consistent, and if you’re in a Group practice, can also help standardize the notes written by your team.
2 Digital Signatures
Sign a piece of paper, and take a photo or scan it. That’s a digital signature! Rather than copying-and-pasting your signature into a word processing document, look instead for a solution that can add your signature easily (along with a date and time stamp, plus your name) in a single click.
3 Real-Time Digital Notes
If you’re comfortable with technology, and don’t find digital note taking during sessions intrusive, consider taking notes on a tablet (such as an iPad) as it happens! Most clients are comfortable with therapists taking notes during sessions, and using a mobile device (rather than a laptop) can also be quite discreet.
4 Note Reminders
To help make sure none of your session note writing falls through the cracks, it’s important to have a system that proactively reminds you of outstanding notes that have yet to be written or need to be finalized and signed.
5 Standardized Headers and Formats
If you ever need to give your session documents to someone (client, lawyer, etc.) it helps to have standardized header information on each note. This note letterhead can contain important information about your practice, your logo, and details about you as a therapist, along with other session details.
6 Notes On-The-Go
A good note-taking tool can let you take notes for a client directly through your smartphone. Take advantage of that downtime between sessions by completing notes while you’re on the go.
7 Revision History Tracking
Most colleges require that you keep a detailed and permanent history of revisions made to your notes, but manually saving multiple versions is time-consuming and error-prone (everyone forgets to save at some point). A tool that can track changes automatically for you can save you time and give you peace of mind that you’re staying compliant.
8 Associated Files
If you’ve got pictures, audio files, or other documents you’d like to associate with a session note, upload the file itself alongside the note you’re typing to give you all the context and details you need.
9 Supervised-Therapist Notes
Supervisors are there to monitor their therapist’s work. Make sure the task of reviewing notes for therapists you supervise is available, easy, and quick.
10 Documentation is Easily Backed Up
Whether your hard drive fails or the storage basement floods, you should never only have one copy of your notes. It’s important that you regularly backup your information, and digital note-taking solutions should always include regular, frequent and secure backups.
Take a look at your current note-taking process. Are there ways that technology might help you do things faster, easier, or more securely? We’ve found that in the long run, it can save you time, enable a more robust and secure note-taking process, and make your daily routine more enjoyable.by