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Do you work as a mental health counselor? Or perhaps you’re studying for an online Masters in Clinical Counseling. Whether you’re a qualified counselor or studying to become one, we have to commend you. It is truly a noble calling to work closely with vulnerable people experiencing a mental health crisis or ongoing mental health issues. You get to work with people when they are at a low point in their lives and help lift them out of that spot. It truly is a deeply rewarding career path.
But there’s much to learn when you become a counselor, including various talk-based therapies such as CBT, DBT and more. Part of the job is also taking client session notes, or case notes, in order to document what occurs in a session and client progress. This helpful article will help you master client session notes, and we’ll cover some of the top dos and don’ts when it comes to taking them. So, continue reading to learn more.
What Are Client Session Notes?
Client session notes, sometimes called progress notes, are a crucial part of the counseling process. Used by clinical counselors, social workers and psychologists, they are clinical documentation notes that outline a client’s progress, setbacks, and achievements in therapy and counseling.
They can be accessed by a client, their family, their insurance company, or other healthcare providers, and as such, need to have a certain level of detail and accuracy. A counselor’s supervisor might also review client notes. They need to include enough detail to allow anyone reading the notes to gain an accurate understanding of the client’s progress through counseling and note any risk and appropriate escalation. It can be tricky to determine what should make it into notes, as so much can happen in a counseling session.
What to Put in a Client Session Note – the DosÂ
In any mental health client session note, you need to include certain things to provide an accurate and full accounting of the client’s status and state of mind. You will always document the date, time, and location of the session, such as whether it is held on-site at your offices or remotely via telehealth.
Next, you will include a brief description of the presenting issue or the reason the client has sought assistance via counseling. This will include the specific nature of the problem, how long the client has experienced it, and any other relevant background information, such as contributing factors like trauma, substance use, or family issues.
As the counseling progresses, it is vital to note the progress the client has made since commencing treatment with you. This can include positive changes to any mental health symptoms, daily functioning, or setbacks, if applicable. If a setback has happened, it is best practice to document why this has occurred if you know the reason or the client is able to identify what has caused this.
The next part of a session note should include a summary of your interaction with the client throughout the session. This can include how the client reports they are feeling, what topics were discussed, and how the client responded to any therapeutic interventions that you used during the session.
Finally, a client session note should conclude with a summary of the counseling session, as well as any goals set or plans for future sessions with the client.
What Not to Include in a Client Session Note – the Don’ts
It is important to note that different organizations and healthcare providers will have their guidelines for clinical note-taking, and you should always be familiar with your employer’s guidance on this. However, we can share some general tips about what not to include in a client session note so you can maintain best practices in this area.
One tip is to avoid heavy clinical jargon or abstract clinical language. You should write a note with the view that the client, their family, or another party may access and read the note, and write accordingly so an outside reader can understand what you are documenting. This is particularly important when it comes to health insurance companies who might review a note, as they need to be able to understand it in order to continue approving the funding for therapy or counseling. If you do need to use clinical language, use it correctly and in a way that it can be understood by someone without your specialized training and education.
Another thing is to avoid making any assumptions about the client, acknowledging that every person you see and treat is a unique individual and deserves respect and unconditional positive regard by you as the counselor. Avoid judgment, assumptions or any thoughts or feelings that aren’t based on your observations. For instance, if you think the client has arrived at a session under the influence of alcohol, which can occur, don’t write, “the client arrived drunk to the session”.
Instead, stick to what you can observe objectively. For instance, “the client was slurring their words, and I could smell alcohol on their breath”. At the same time, you can’t pass judgment on a client in a clinical note. It is not appropriate to write “the client is being difficult” or “the client is not making an effort”. Always stick to what actually happened and what you can observe. For instance, “the client gave one-word answers to my questions” or “the client refused to answer my question about” a certain topic.
If Your Client is Suicidal
Finally, we need to touch on this topic. People with mental health issues can experience suicidal ideation, where they think about suicide. Some clients may even tell you that they are contemplating suicide or they have a plan to suicide. As a counselor, you have a duty of care to your clients. If this is brought up, it needs to be documented, and if you assess that there is a real risk of suicide, you may have to notify the relevant authorities such as the local mental health crisis service or 911. This should be explained to the client when they commence treatment with you. In this case, you need to document the process. For instance, you might write:
“The client presented to their session and told me they were suicidal and had the means to suicide. I informed them that I have a duty of care to them and needed to escalate this to my manager and inform the relevant authorities”.
It is incredibly important that you both accurately document this and make the appropriate referrals or reports if someone discloses plans to end their life.
A Client Note Summary
As a counselor, client session notes are an incredibly important part of your job, in order to accurately document client sessions and maintain accurate records of their mental health care. Here, you’ve learned the essential dos and don’ts for taking accurate and correct client session notes, which you can incorporate into your practice or learning.
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