How do mental health professionals keep up on their case notes?

Question

Could someone share their method for keeping up on these tasks?

Answer 1

I'm a Licensed Clinical Social Worker, and I document all my contacts with my therapy clients (which is required, of course). Over the years I have just learned to abbreviate my documentation/notes using the medical format. And basically I condense presenting issues, document what I did (interventions), and then chart the outcome. These three things are what I try to adhere to for every visit with every client. This shows whether there is progress or not and offers me the insight to judge if a certain intervention is working or not. Keeping the responsibility for progress on the client(s) at all times frees you up to observe, document, and provide suggestions/interventions. Hope that helps.

Answer 2

I am a clinical Social Worker in the Federal system. I normally do all my notes daily or at least within 24 hours.

I use templates for basic info that rarely changes as well as for headings in areas I normally address for each visit. I take notes for issues that were presented, how we/I dealt with them and what the plan is for the person.

I normally can keep all this in my memory, but if I am having a rough day I either take hand written notes or use my PDA.

The templates are a godsend as they allow me to have a system for my notes that I can individualize for each client.

Answer 3

I don't know how they do it . My nut Dr. told me i was a real challenge. That I do thing that even she had never heard of. She said i was so conplexed that she was goin to have to have help with me. LOL to me i think it's funny maybe i am different but i am me and that's the way i am..Oh my nut Dr. uses a recorder to keep up with all we talk about lol she told me that even a recorder coulden keep up with me!!But i am a nut what can i say except this....did i win....did i win....did i win!!!!

Answer 4

They dictate them to medical transcriptionists.