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

What is mental health?

Mental health is an individual's emotional, social, and psychological well-being. It significantly impacts our thinking, feelings, and interactions with our environment. Mental health practitioners and other health care professionals are trained to strengthen and improve mental health so that individuals can comfortably and confidently function in all spheres of their lives. Mental health professionals help people deal with life stressors, regulate emotions, and improve their health.

One consistent element across all mental health clinicians is maintaining clinical notes and documentation. Mental health progress notes are required, and legal documentation outlines the patient's symptoms, diagnosis, and treatment plan following every session. These are essential in the mental health field as they are used to determine any improvements or changes noticed in the patient and be a reference for specific third parties, including other healthcare professionals, insurers, and lawyers.

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. 

• 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.
• 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 healthcare quality.
• Legal document: 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. 

Maintaining good clinical documentation critically helps to protect patients and practitioners equally. This is why it can be helpful to use healthcare software that integrates client data with digitized health records when you write progress notes.

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. To ensure these barriers are eliminated, we have compiled a list of mental health practitioners' most frequent challenges 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.

Having organized notes allows you to access critical information at just one glance and can help you save time and energy when searching for specific information. It's highly effective and ensures you're always providing high-quality patient care. 

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. 

Knowing when to take notes can help strengthen professional relationships and ensure you're actively listening to your patients' experiences. It goes one step beyond what is required and can help clients feel valued in your clinic. It also ensures that no critical information is missed and that you are building long-lasting professional connections.  This is also especially helpful when writing group therapy notes where you consider a group as a whole, which involves more observations.

3. Quality over quantity

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. 

Quality medical or psychotherapy progress notes allow you to elevate success in healthcare outcomes and ensure you've noted all relevant details. By having rich data, fellow healthcare professionals can easily understand your assessments, and you can gain greater medical expertise.  

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. 

Incorporating objective information gives valuable insights into your patients' healthcare journey and treatment. You can better understand the issues and develop plans addressing root causes. You can practice this using a structured progress note template as a reference.

5. 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.

Having HIPAA compliance standards can safeguard your clinic against potential threats and ensure the longevity of your business. Additionally, you can save time and money by protecting yourself against costly charges and data breaches. 

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'd 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.

Providing digital notes can increase clinical outcomes and ensure that patients consistently receive a high level of care. Fellow healthcare professionals can review your notes quickly, and clear notes can be used as reliable reference points in future cases. They're also much more efficient at writing! 

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.

Some things are helpful to the client's mental health progress, and others are not, so you must know how to make this distinction. For instance, you can specify what coping skills, mindfulness techniques, stress management strategies they can practice or any medical necessity the client requires. It is also essential to be specific and accurate about how the client responded, which you can do by using direct quotes instead of personal comments.

Concise and specific details ensure you get the point across with as little effort as possible. You can save time that can be spent on other business operations, and you can also adequately represent the client's experience without compromise. Using concise, simple language, you can produce valuable insight that can be effectively utilized towards treatment, cutting straight to the point. 

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!  

Having the correct anonymous information can strengthen your reputation and allow you to maintain privacy and confidentiality regarding your client's wishes. You can comply with professional standards and ensure you aren't overstepping your boundaries. This also extends to how you construct and communicate a client's record or your psychotherapy notes, especially during consultations or group discussions with colleagues.

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.  

Complying with legal standards and documentation requirements can protect you against extensive fines and charges that not only are a hassle to deal with but can also severely damage your clinic's reputation. Clients are more likely to trust your services, and you can feel at ease knowing you're doing the right thing. 

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.

Shortcuts can be intensely confusing to others, leading to misinterpretation and miscommunication. As a result, it's best to avoid them altogether and minimize the risks of the wrong treatments being allocated. 

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Writing perfect 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 in 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.

A take-home message for mental health professionals

Carepatron is an all-in-one practice management software that can provide your practice with the necessary tools to create practical progress notes and stay on top of your clinical documentation. The user-friendly system offers resources catered to many mental health practitioners, allowing your practice to streamline its documentation and stay on top of writing progress notes!

Consistent documentation of your present and next session with patients is an essential service 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.