What Is Mental Health?
Mental health refers to an individual’s emotional, social and psychological well-being. It has a significant impact on how we think, feel and interact with the environment around us. Mental health practitioners, including psychologists, psychiatrists, counselors, and therapists, are trained to strengthen and improve mental health so that individuals can comfortably and confidently function in all spheres of their lives. Mental health practitioners help people deal with the stress in their lives, regulate their emotions, and develop meaningful relationships with others. Data from the National Center for Health Statistics reported that in 2019, 19.2% of adults had received mental health treatment in the previous 12 months.
One element that is consistent across all mental health practitioners is the importance of maintaining clinical documentation. Mental health progress notes are a required and legal form of documentation that outlines the patient’s symptoms, diagnosis, and treatment plan following every session. They are used to determine any improvements or changes noticed in the patient and be a reference for specific third parties, including other healthcare providers, insurers, and lawyers.
Skip to sections:
- Why is it important to take notes in mental health?
- What are the common challenges to writing notes in mental health?
- Writing a perfect mental health progress note (example)
- A take-home message for practical progress notes
Why is it important to take notes in mental health?
When it comes to mental health, taking progress notes has many benefits for both practitioners and patients.
- Tracking Improvement: Keeping a record of a patient’s progress after each session allows the practitioner to numerically measure their improvement or any other noticeable changes in mood or behavior. This allows the practitioner to adjust treatment plans where necessary.
- Communication: Progress notes can effectively improve contact between the practitioner, patient, other healthcare providers, and family members. This ensures that all of the patient’s carers understand treatment plans and interventions to guarantee the best healthcare quality possible.
- Legal Document: Progress notes are a legal document that assists in insurance claims. They can also be requested by legal teams in the unfortunate case of a dispute or lawsuit. When this happens, having clear, concise, and consistent progress notes will provide evidence for your patient’s treatment.
Maintaining good clinical documentation critically helps to protect patients and practitioners equally. Writing practical progress notes can be assisted by utilizing healthcare software that integrates client data with digitized health records, streamlining an otherwise time-consuming and demanding process.
What are the common challenges to writing notes in mental health?
The importance of writing good progress notes in mental health shouldn’t be underestimated. Various challenges are faced by mental health practitioners when maintaining their clinical documentation. To ensure these barriers are eliminated for you, we have collated a list of the most frequent challenges mental health practitioners face and how they can be avoided. If video content helps you absorb information easier, we also have included a valuable resource on how to improve notes with professional advice.
Organization: Staying on top of your progress notes can be difficult, especially if you see numerous patients. Given how frequently progress notes are shared between third parties, they need to be accessible at all times. We recommend using software that organizes clinical documentation for you, ensuring it is easily accessible and formatted correctly.
Insight: Having organized notes allows you to access critical information at just one glance, and can help you save time and energy when searching for specific information. It’s highly effective and ensures you’re providing high-quality patient care at all times.
When to take notes: Excessive note-taking during a session can make patients nervous and prevent you from giving your full attention. On the other hand, waiting too long to write your notes can lead to forgetting relevant information. The best solution to overcome these challenges is writing your progress notes immediately after every session with a patient.
Insight: Knowing exactly when to take notes can help strengthen professional relationships, and ensure that you’re actively listening to your patients’ experiences. It’s going one step beyond what is required and can help clients feel valued in your clinic. It also ensures no critical information is missed, and that you are building long-lasting professional connections.
Quality over quantity: Writing practical mental health progress notes can lead to excessively vague language, resulting in unnecessarily lengthy documentation. The key to a good progress note is using brief, concise language. Typically, a progress note should take no more than 10 minutes to write and only contains direct relevant information.
Insight: Quality notes allow you to elevate success when it comes to healthcare outcomes, and ensure that you’ve noted all relevant details. Fellow healthcare professionals can easily understand your assessments, and you can gain greater medical expertise in having rich data.
Objectivity: Maintaining professionalism is a crucial element to writing a practical progress note, and the best way to do this is to be objective. A patient shouldn’t be described as being “aggressive” or “hysterical.” Instead, focus on the behaviors and language of the patient that point to how they are feeling. While writing your progress notes, make sure you are mindful of your perceptions and biases.
Insight: Incorporating objective information allows for more valuable insights when it comes to your patient's healthcare journey and their treatment. You can better understand the issues at hand, and develop plans that address root causes.
HIPAA-compliance: Progress notes contain private and confidential information relating to the patient, including their symptoms, treatment goals, diagnosis, and medical history. After you have written your progress notes, you need to keep them in a secure location. This could be as easy as storing them in a locked cabinet, saving them on a password-protected Word document, or utilizing a HIPAA-compliant healthcare platform.
Insight: Having HIPAA compliance standards can safeguard your clinic against potential threats, and ensure the longevity of your business. Additionally, you can save large amounts of time and money by protecting yourself against costly charges and data breaches.
Save time by using digital notes over handwritten notes: Sometimes notes need to be compiled quickly, and when you add a heavy workload into the mix, many notes are neglected in terms of clarity. In some legal cases, it was actually beneficial to keep illegible notes, as no one could understand what you’d written, meaning you have the freedom to justify whatever position you take. However, this is very inconvenient, not to mention frustrating when working with other healthcare professionals, and so it’s important that you maintain digital notes for clarity, and to showcase your professionalism.
Insight: Providing digital notes can increase clinical outcomes, and ensure that patients are consistently receiving a high level of care. Fellow healthcare professionals can review your notes easily, and clear notes are able to be used as reliable reference points in future cases. They’re also much more efficient to write!
Avoid using vague language: It can be tempting to include all information that occurs within a session with a client, especially as it paints a clearer picture. However, part of being a mental health professional is realizing that not all information is good information and that being specific is key. Some things are useful to the client’s mental health progress, and others are not; so it’s important you know how to make this distinction.
Insight: Concise and specific details ensure you get the point across with as little effort as possible. You can save time that can be spent on other business operations, and you can also adequately represent the client’s experience without compromise. Using concise, simple language, you can produce valuable insight that can be effectively used towards treatment, in cutting straight to the point.
Do not quote and mention the patient's name unless necessary: There can be a fine line between using general and specific details when it comes to client progress notes, but it’s important that you recognize this boundary. Sometimes third-party and patient quotes are not critical to your client’s records, and including identifying information can result in privacy violations. This is especially important if your notes are used in a legal case!
Insight: Having the right anonymous information can strengthen your reputation and allow you to maintain privacy and confidentiality, with respect to your client's wishes. You can comply with professional standards, and ensure you aren’t overstepping your boundaries.
Adhering to legal requirements: It’s likely you won’t be from a legal background, and in that case, it can be difficult to keep up with and understand legal regulations and standards. Especially considering they can update frequently and without warning, which is a little daunting.
Insight: Complying with legal standards can protect you against extensive fines and charges, that not only are a hassle to deal with but can also severely damage your clinic’s reputation. Clients are more likely to trust your services, and you can feel at ease knowing you’re doing the right thing.
Know when to include or exclude information: It’s important to summarize notes to ensure they’re concise and cut to the point for quality purposes. Spend some time learning what to include, and what to exclude, as not everything is relevant to your notes. You can save valuable time, and ensure that you provide value elsewhere. However, it can be challenging to know what to include, especially when dealing with suicidal clients. In the case of legal reasons, you should never skimp out on explanations when it comes to risk management and explaining the client's experience with suicide attempts.
Insight: It’s a learning curve to know when to include information and when to exclude it. For instance, suicide is a heavy topic, and it should not be disregarded. Providing accurate details can save lives, so make sure that you include all details for a good legal defense, and for treatment that can work towards making actual progress.
Avoid taking shortcuts in the notes: While shortcuts are convenient, keep in mind that others will also likely be reviewing your progress notes. As a result, you need to ensure that everything you jot down is easily understandable - which means no shortcuts.
Insight: Shortcuts can be intensely confusing by others, and can lead to misinterpretation and miscommunication. As a result, it’s best to avoid them altogether and minimize the risks of the wrong treatments being allocated.
Writing a perfect mental health progress note (example)
Overcoming these challenges and getting into the habit of writing practical progress notes is the key to ensuring practitioner and patient protection. Although keeping clinical documentation can seem like a time-consuming task, it is essential to remember that progress notes don’t have to be extended as long as they contain all relevant information.
Cutting down on the amount of time you spend writing notes can be assisted by using a formatting guideline, like SOAP. These notes separate the information into four different sections, maintaining consistency and clarity. Below is an example of a practical SOAP note written by a counselor.
- Subjective (S): The patient stated that she “feels better today than I have in a while.” Her sleeping pattern is more regular, at 6 hours per night. She says she finds it easier doing daily activities, like grocery shopping and seeing friends. She can feel herself “improving.”
- Objective (O): The patient’s compliance with medication is suitable. She has maintained sobriety. Her relationships with her family and friends are improving, and she has retained steady part-time employment for six months.
- Assessment (A): The patient presents as attentive. Her speech is normal, and she engages in conversation. The patient shows no indicators of hallucinations, delusions, or other psychotic processes. The patient is fully-oriented, and her insight into problems appears normal.
- Plan (P): The patient will keep taking the current course of medication and attend weekly counseling sessions.
Eliminating some of the other challenges involved in writing good progress notes can be solved by using specific digital platforms. Mental health software for practitioners provides progress notes templates, in addition to HIPAA-compliant storage options.
A take-home message for practical progress notes
Carepatron is a digital healthcare software that can provide your practice with the necessary tools to create practical progress notes and stay on top of your clinical documentation. The system is user-friendly and offers resources catered to many mental health practitioners, allowing your practice to streamline its documentation and stay on top of writing progress notes!
Consistent documentation of your sessions with patients is an essential service offered by mental health practitioners. Writing good progress notes has just as many advantages for the practitioner as it does for the patient, so make sure you utilize the available resources to help you, and remember - be clear, concise, and consistent.