Mental Health Notes | 10 Common Challenges and Fixes to Taking them

Why is it important to take notes in mental health?

When it comes to mental health, taking mental health progress notes has many benefits for both practitioners and clients. Maintaining good clinical documentation, including tracking client progress and noting therapy progress, critically helps to protect both patients and practitioners equally. Detailed progress notes allow therapists to assess the effectiveness of interventions like cognitive restructuring, monitor the client’s response to treatment, and evaluate the development of coping skills. Here are some reasons why taking notes is essential

Tracking improvement

Recording a client's progress after each session allows the practitioner to numerically measure their improvement or any other noticeable changes in mood or behavior. This process starts when a client reports their symptoms and continues until adjustments in treatment plans are necessary. These notes are essential for ensuring the therapy remains focused, personalized, and responsive to the client’s needs.

Communication

Progress notes, whether for an individual or a group note, can effectively improve contact between the practitioner, patient, other healthcare providers, and family members. This ensures that all patient care providers understand treatment plans and interventions to guarantee the best quality of healthcare.

Legal documentation

Progress notes are legal documents that assist in insurance claims. In the unfortunate case of a dispute or lawsuit, legal teams can also request them. When this happens, having clear, concise, and consistent progress notes will provide evidence for your patient's treatment. 

What are the common challenges to writing notes in mental health?

Writing good mental health or therapy notes shouldn't be underestimated. Mental health practitioners face various challenges when maintaining their clinical documentation, especially when it comes to writing progress notes for mental health.

To ensure these barriers are eliminated, we have compiled a list of mental health practitioners' most frequent challenges or considerations and how they can be avoided.

1. 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. This is important in medical record keeping. We recommend using software that organizes clinical documentation for you, such as an electronic health record (EHR) system.

2. When to take notes

Excessive note-taking during a therapy session can make patients nervous and prevent you from giving your full attention. On the other hand, waiting too long to write 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. 

3. Conciseness of notes

Writing practical mental health progress notes can lead to excessively vague language, resulting in lengthy documentation. The key to a good progress note is using brief, concise language. This should include necessary information such as history, how the client presents in session, assessment results, and next steps. Typically, a progress note should take no more than 10 minutes to write and only contain direct, relevant information. 

4. Objectivity

Maintaining professionalism is a crucial element of writing a practical progress note, and the best way to do this is to be objective. A client's behavior shouldn't be “aggressive” or “hysterical.” Instead, please focus on the behaviors and how the client responds to indicate their feelings. While writing your therapy notes, make sure you are mindful of your perceptions and biases. 

5. Health Insurance Portability and Accountability Act (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.

6. Manual note-taking

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, keeping illegible notes was beneficial, as no one could understand what you've 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, so it's vital that you maintain digital notes for clarity and to showcase your professionalism. You can do this by using software that can help you generate progress notes from your existing ones and edit them to make them more comprehensive.

7. Vague language

Including all information within a session with a client can be tempting, primarily as it paints a clearer picture. However, part of being a healthcare professional is realizing that not all information is good and that being specific is vital. Try to avoid vague or subjective language within notes.

8. Confidentiality issues

There can be a fine line between using general and specific details in client progress notes, but you must 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.

9. Adhering to legal requirements

Likely, you won't have a legal background; in that case, it can be challenging to keep up with and understand legal regulations and standards. This is especially true considering they can be updated frequently and without warning, which can be daunting.  

10. Shortcuts

While shortcuts are convenient, others will likely review your progress notes. As a result, you need to ensure that everything you jot down is easily understandable—which means no shortcuts and including all relevant information, especially client responses and some direct quotes.

Writing mental health progress notes (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 time-consuming, it is essential to remember that there are ways to write good progress notes more efficiently.

Using a formatting guideline, like SOAP notes, can help you reduce the time you spend writing notes. These notes separate the information into four sections, maintaining consistency and clarity. Below is an example of a practical SOAP note written by a counselor. 

• Subjective (S): The patient stated 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 to do 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 every day, 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 continue taking the current medication and attend weekly counseling sessions.

Take-home message

Consistent documentation and therapy progress notes of sessions with patients are essential services mental health practitioners offer. 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 remember—be clear, concise, and consistent.  

Whether you're working on SOAP progress notes or tracking the patient's treatment journey, the progress note writing process plays a critical role in shaping future sessions.