How to Take Good Client Notes (and Record Keeping)

Good Morning–

I am trying to get clarity as to the distinction between counseling “records” and counseling “notes”.  Specifically, I am looking for a simple, easy-to-use format for maintaining records and notes that meets HIPAA requirements, protects my clients, and provides me with the detail I need to maintain continuity between sessions.  I have an individual practice in Idaho.  I do not have office staff and do not bill insurance.  I am finding a range of complex and conflicting advice and debate on this issue, and am feeling insecure about my own system, but also feeling frustrated at not finding anything that is likely to work better.  I would appreciate your input.

Thank you,

Mary O.

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ANSWER:

Greetings Mary,

My name is Anthony Centore, I am a private practice consultant for the ACA.

You present good questions in your email! Let’s see if I can help….

First, counseling “notes” and counseling “records” are terms that are often used interchangeably, in casual discussion, but they technically are different. To be more specific, a client’s record would include informed consent documents, intake forms, and perhaps special permissions for the release of information; basically, anything kept on file for a particular client would constitute their record. A client’s counseling “notes” generally refers to their “session progress notes” specifically. A popular format for writing these notes is SOAP, which stands for Subjective, Objective, Assessment, and Plan.

In regards to finding a system to take and keep notes, you are not alone in your frustration, as finding a good record keeping system is something on a lot of counselors’ minds these days. Fortunately, the task is made somewhat simpler by the fact that you don’t bill insurance.

Mary, for your solo-practice, you could create paper-based notes, using the SOAP format.

You could take the notes during and after client sessions, and store them in a double-locked filing cabinet. I would recommend getting a book on setting up your system–to get started.

The “Adult Psychotherapy Progress Notes Planner” is a good book that will provide in-depth and step-by-step direction, as well as templates that you can photocopy for your use in your practice (I think the book now also comes with a CD, which contains templates in electronic format).

You can find the book, and others like it, here:

Mary, if you’d like a more high-tech/paperless solution, there is a nice online solution available (for free!) at PracticeFusion.com (the health record component is free, the billing component costs money–so it’s a great option for you, as you don’t need billing). This is a web-based note-taking/record-keeping program, and also comes with a calendar that you can use to schedule your clients.

Mary, I hope this was helpful. If you have any more questions, please feel free to ask!

Sincerely,

Anthony Centore Ph.D.