Therapy Notes: How to Document Gray Areas

Therapy Notes: 5 Tips for Clinicians

Documenting Gray Areas: Risk Assessment for “Medium Risk” Clients

All counselors understand that high risk situations, such as a client reporting suicidal thoughts, require significant and timely therapy notes. However, what about the gray areas we encounter on a daily basis? The situations that linger and don’t quite meet the “high risk” threshold?

That’s exactly what we’ll be discussing in this post – what to write for your “medium risk” clients who don’t keep you up at night worrying about their outcome, but also don’t leave you worry-free each week.

Now, I want to start by saying that I do NOT take the approach of wanting to scare everyone into writing excessive amounts of therapy notes, as you may have heard when attending workshops run by lawyers or malpractice insurance organizations. Many clinicians are used to an all-or-nothing approach where they either write very little or feel as though they need a transcript of what happened in the session.

The key is identifying when you need to be more aware, what to include in your notes on a regular basis, and how to make your notes express what transpired in a meaningful way.

It’s also important to have an approach that allows you to write in the long-term. While crisis sessions tend to be a significant event that then winds down over time, medium risk situations can last for quite a while. That’s why having a realistic approach that covers all your legal and ethical bases, while also allowing you to get your therapy notes done in a reasonable timeframe is important.

Defining Medium Risk

First, let’s define what we mean by “medium risk” situations. These tend to be ongoing needs that require some assessment but in which the outcome is not likely to be severe enough to require a report or hospitalization.

Some examples of medium risk presentations include:

• Self-harm behaviors not identified as related to suicidal ideation
• Moderate and severe depression
• Impulsivity and adrenaline-seeking behaviors
• Substance use

Identify What is Relevant

As discussed in Suicidal Ideation: How to Document on assessing suicide risk, you’ll want to make sure you include in your therapy notes details along the way that shows an ongoing assessment of risk factors, protective factors and safety planning. However, since these situations tend to be more chronic than acute, it may be fine to reference previously obtained information or situations, rather than constantly writing everything out in each note.

For example, if you’re working with a client who is expressing moderate depression, you’ll want to continue assessing their symptoms to ensure you’re aware of any increase. However, if they’ve never expressed suicidality, you may not need to do a risk assessment every session.

Please note that I do recommend you ask every client about any history of or current thoughts related to suicidality when you begin treatment, particularly if the client presents with depressed mood. Based on that information you gather, you will then determine how to best proceed.

If you do feel it is necessary to include information about denial of suicidal ideation in each note for a period of time, it can simply be a brief note rather than a full account of the risk assessment. Of course, these are circumstances in which you want to use your clinical judgment, but I advise against treating each client exactly the same.

Document what is relevant for each client and if suicidal ideation has never been an issue, there is no reason to write about it in every client note. In fact, I would not write about it unless you actually asked or assessed the client. Many clinicians will routinely check a box that says “No suicidality” or will write “Denied suicidal ideation” without even asking the client about it during that session… because it truly wasn’t relevant.

One scenario may be a client who is seeing you for stress related to work, has never expressed any suicidal ideation (and denied it during your first sessions), is making vast improvements and is now only seeing you twice per month. This client does not need a regular note about this because she is low risk and most clinicians are not actually discussing the topic of suicidal ideation with her each session.

Basic rule: keep your notes to what you actually do in session! Don’t include random things others may have told you “need” to be there but don’t actually relate to what you’ve done.

Review a Real Note

That probably sounds too simple, but let’s explore further for our medium risk clients. So, what would a note for a medium risk client actually look like? Let’s look at an example.

Below is an example using the DAP (Data, Assessment, Plan) template for writing therapy notes. This note is for an imaginary client who is a 36 year old male that reports being depressed “for most of my adult life” at intake and currently has no motivation to work:

Data: Client discussed his lack of motivation for work and reported missing work 3 days last week. Also reported feelings of guilt around this. Identified depression at a 7 of 10 with no increase since previous session. Continues to identify children as his reason for days when he is able to motivate himself to go to work. Discussed ways to increase motivation and identified ways to implement during the week. Denied any suicidal ideation.

Assessment: Client continues to experience moderate depressive episode and is ambiguous regarding motivation. Had difficulty accepting praise from me when I noted his continued commitment to therapy. He became engaged in task of identifying ways to incorporate his children more into the work.

Plan: Next session scheduled for 6/30/17. Client will call to report if depression increases prior to that and will implement strategies discussed in session, reporting back progress for next session.

This therapy note focuses on any fluctuations in symptoms, an assessment of the present condition, continued motivation for treatment and identifying tools to move through treatment. The focus is on his actual treatment and the presentation related to that.

The note mentions that the client denied suicidal ideation, since his depression is continuing to be monitored. However, a full assessment identifying all protective and risk factors is not needed since there was no present concern.

One Quick Tip

Lastly, these scenarios speak to two crucial things that are important but often overlooked in private practice settings- having other clinicians review your therapy notes and reviewing your own documentation regularly.

I always recommend that clinicians schedule just one hour per month (or even every other month) to review client notes. That means sitting down with the file or at your computer, starting with the beginning, and reading each note as a story.

Ask yourself if the notes seem to capture what you feel is happening in session. This is also a great opportunity to realize when you may be missing something important, or to identify trends that may not be so apparent when you’re in the day to day work.

You’ll also quickly be able to recognize if you are documenting the risk level for your clients. And if it is hard to tell? That’s when you ask a trusted colleague to do a review for you. Note that quality reviews are covered under HIPAA, meaning that it is acceptable to allow a colleague to do so. However, you’ll want to make sure you are only providing the minimum necessary (if you can hide names and other info, that’s ideal) and that you are working with a colleague you know and trust.

Ask them to explain the case to you after reading through it and whether or not they have questions. This will help you see any blind spots you have and if what is happening in the room is making it to paper.

Using the strategies above should help you to actually save time on documentation in the long run, while still making it a meaningful part of the treatment that fulfills your ethical obligations.

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About the Author: Maelisa Hall, Psy.D. specializes in teaching therapists how to connect with their paperwork so it’s more simple and more meaningful. The result? Rock solid documentation every therapist can be proud of! Check out her free online Private Practice Paperwork Crash Course, and get tips on improving your documentation today.

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