Session 30: Practical Tips for Easy Case Notes



Welcome!  My guest today is Dr. Maelisa Hall, who is a licensed clinical psychologist with an unusual passion:  PAPERWORK!  Yes, Maelisa loves that mundane, often-overlooked, and most dreaded aspect of our profession.  Her goal is to help therapists create relevant documentation that frees them to spend more time in therapy with their clients.  She has created training workshops and valuable tips and resources that can help any practitioner to LEARN TO LOVE PAPERWORK!

Maelisa discovered her niche while transitioning from PT to FT work when she accepted a job as a “quality improvement specialist.”  She found that she loved providing training for therapists and agencies and saw that she could provide a service for a need not yet being met.

Maelisa shares her insight with us about the following topics:

  • INTAKE PAPERWORK can be a conversation starter for the therapy process and not just a necessary chore.  Use this time to explain the therapy process and the client/therapist relationship.
  • CONFIDENTIALITY should be thoroughly explained to the potential client.  Legal limitations vary from state to state but make sure the client knows how you will guard their confidence.
  • INTAKE CONVERSATION involves asking many questions, but can also build immediate rapport and comfort for the client.  Think of this step as the “intro” to their story.
  • INTAKE ESSENTIALS include explaining the therapy and the therapist’s role while normalizing the fear and nervousness of the client.
  • CASE NOTES must be legal but meaningful.  Consistency is the key.

Maelisa’s helpful tips on writing case notes deserve a closer look:

  • HAVE A SCHEDULE, whether that’s after each session, at the end of the day, the day after the session or once weekly.  Do what works for you and not what other therapists do!
  • USE A TEMPLATE; it helps trigger your memory concerning what to include.  Maelisa created “Meaningful Templates,” which are reflective-based notes.
    • One basic template is D-A-P, which stands for data, assessment, and plan.  The data explains what actually happened in the session.  The assessment is the clinical assessment of what needs to change.  The plan is the “what next?” aspect of the session.
    • One template is a Results-Based Note, which asks three questions.  What did the client identify as the original goal of therapy?  What would the client say is the current goal and how does it relate to the original goal?  How did we work together toward those goals today?
  • VISUALIZE what the client might do next based on what happened in the session.  Think objectively.

Maelisa says some clinicians make mistakes on case notes that lead to inefficient documentation.  Some of these include overlooking the “Plan” section of the template, and not making detailed notes because “I’ll remember that.”  Don’t trust your memory!  I hope you’ll join us for this episode, learn to view paperwork differently, and tap into Maelisa’s wealth of information.  Join us for more!

Links and Resources:    (Maelisa’s website, which includes her blog, videos, resources, newsletter)

Melissa's free online Private Practice Paperwork Crash Course:

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