Proper documentation is the backbone of your practice, but even with technology, providers can struggle to get timely notes after a session. Some providers opt to take notes in real-time during the session. While taking notes during sessions can help providers write important details they could forget after a session or add context like the client’s emotional state, it can also lead to clients feeling disconnected and unimportant. However, there are a few ways in which mental and behavioral health providers can take real-time notes with their EHR while still maintaining a warm and attentive client-provider relationship.
Before we begin, we should highlight that taking notes during sessions is not for everyone. Some people struggle with multi-tasking or feel they’re not paying enough attention to their clients. That’s valid. Everyone works differently, and you should recognize your strengths and weaknesses to work effectively. Don’t force yourself to take notes in real time if you feel it hurts your therapeutic skills.
Break the Ice
When beginning a session with new clients, it’s important to explain how you will be taking notes (for example, typing on a computer or recording the session). If you choose to record clients using a recorder or telehealth session recording, make sure you obtain their consent.
Before you begin taking notes, explain to your client that you will be taking notes in real-time, why you’re doing it, and if it’s okay with them. Doing this upfront will help ease their anxiety or discomfort about your writing while they are speaking.
Your client may be uncomfortable or refuse to be recorded or have you take notes during the session. In that case, it might be best do these notes after the session. It might be less convenient for you, but it’s important to create a healthy relationship with your clients, and encourage healthy pushback when applicable.
Your Tools Should Be Unintrusive
It is important to position the computer or tablet and the client in a way that doesn’t create a feeling of distance between you. If possible, place the computer at an angle so you can still make eye contact with them. This will help the client feel more included during the session. If your EHR is mobile, consider using a tablet to type notes while sitting closer to the client. Avoid using loud note-taking tools that could bother the client. If your keyboard is noisy, consider using a different one.
Use Templates to Save Time
EHRs often come with pre-built templates for common diagnoses and treatments. These templates can save time by providing prompts and fields to fill out with information that can pre-populate client notes. Using templates can help you maximize your time with the client and lessen the time spent documenting each session.
Your EHR may also offer an optional Wiley integration. Wiley allows providers to save considerable time on notes by offering pre-written statements with evidence-based treatment plans, so you can complete highly detailed documentation with a few clicks.
Some EHRs also offer dynamic notes, which allow you to pull information from previous notes and fill out fields with information you already have. For example, you could bring notes from your previous session and edit them to speed up the process.
Use Brief Notes
Nobody enjoys long-winded notes that read like a novel. Use brief notes that capture the essence of the conversation and any important details discussed. When you need to add context, could add summary-type notes like, “major changes to medication prescribed,” or “significant life event discussed.” You don’t need to capture everything in perfect detail; write enough that you can fill it out later but not so much that it prevents you from talking to your client. Even with insurance, while you may need specific detail to document medical necessity, your notes don’t need to be lengthy.
Be Present
While it is important to document, it’s also crucial to be present during the session. Active listening and engagement can help strengthen relationships with clients and improve their outcomes. If the client needs a moment before starting the session, allow the person to take their time and just make notes on important details.
Don’t forget to make sustained eye contact and look at your clients while you speak to them. Don’t spend the entire time typing and looking at your notes when your client is speaking, or you might look disinterested. This is especially true if a client is emotional or sharing something very personal. Don’t forget, your client comes first – notes are important but should not detract from the help you provide during the session.
Review the Notes
Before ending the session, take a few seconds to review the notes gathered during the session, ask for feedback from the client to ensure accuracy, and see if anything needs to be modified. This will give you the chance to emphasize key points of the session and ensures that you have captured essential information.
If there are notes that the client should not be privy to, format them in a way that lets you know to skip them during the recap to avoid slip-ups.
Using your EHR to take notes in real-time doesn’t necessarily mean that you have to compromise the client-provider relationship. The key to maintaining a healthy relationship while using EHRs is being present and using technology wisely. Explain to the client why you’ll be taking notes, strategically place the computer to maintain eye contact, use brief and accurate notes, and actively engage with your client throughout the session. By keeping these tips in mind during your next session, you can reap the benefits of real-time documentation without becoming disinterested.
TheraNest has the tools you need to take fast, efficient notes during and after sessions. Whether you need templates or word banks, our EHR will help you spend less time typing and more time caring. Start your free 21-day trial, no credit card required.
