Paperwork Therapy: Blog
I’m here to heal your paperwork
Therapy paperwork can be a pain, let me help.
My name is Cat Maness, and I am a licensed psychotherapist in the state of California. In addition to running my own private practice, I have experience as a Quality Assurance Coordinator for a small mental health agency.
What is Quality Assurance?
In the therapy world it means assisting others in being aware of, and adhering to, all current legal and ethical duties related to the practice of psychotherapy. When working for an agency with associate clinicians, this meant training in proper paperwork creation, maintenance, and problem-solving. In addition, I would help guide the agency in their policies to ensure that we remained legally and ethically above board.
I created Paperwork Therapy to help share my knowledge and expertise around therapy paperwork. I’ve made available in my Etsy shop an entire suite of documents that you can purchase and download instantly. These forms will cover most, if not all, of your clinical needs as well as practice management functions. And you can rest assured knowing that all these forms have been created and vetted by a quality assurance professional.
I look forward to providing you with a blog post that relates to the creation and utilization of therapy paperwork each week. We’ll also spend time together looking at some of the practical, ethical, and legal questions that tend to come up around paperwork and running a private practice.
Translating Progress Note Formats
SOAP. DAP. BIRP. DART. What do all these acronyms mean?? I’m here to tell you!
In this series, I’ll be reviewing different types of common progress notes, how to fill them out, and why they’re important.
Types of Progress Notes
Let’s start with simply putting those acronyms into words:
SOAP = Subjective, Objective, Assessment, Plan
DAP = Data/Describe, Assessment, Plan
DART = Description, Assessment, Response, Treatment Implications/Plan
BIRP = Behaviors, Intervention, Response, Plan
When it comes down to it, they all look pretty similar, don’t they? Their structure follows these basic sections:
Why is there no universal progress note format?
If all these progress note formats are so similar, why use different formats at all? Why isn’t there just a universal progress note format?
The reason why there is no universal progress note format is that it would be impossible to capture all the different data needed for specific situations. What you need to record in a private practice setting can be quite different from what needs to be recorded in an inpatient hospital setting. In fact, even these basic progress note formats are often personalized even further to suit the clinician’s and/or clinic’s needs.
For example, in the community mental health agency where I worked, we primarily followed a SOAP format. However, we also needed to address the BIRP requirements of our local Medicaid office. So, I ended up creating a hybrid progress note that could address both needs.
Progress Note Examples
In this series I will be providing an example of each progress note type using the same fictional session between a therapist named Mary Brown and her adult client, Jane Smith. You’ll have the chance to see what the same data would look like across all the different note formats.
SOAP Progress Notes
Let’s start off by translating the acronym SOAP. It stands for:
Now we’ll go over the note, section by section.
In this section you describe the client’s subjective position regarding the session content. Most often it is suggested that you use direct quotes from the client. This is essentially the client’s primary complaint or presenting issue in the session. You can also summarize session content here.
I’ve also occasionally seen clinicians who include their own subjective experiences of the session in their notes. Though I would caution you to be careful to keep your progress note content separate from any process (or “psychotherapy”) notes you may want to write about your client.
This section is for recording only objective and factual data, such as client behavior and other observations from a mental status exam, whether formal or informal. You can also note things such as tardiness, safety precautions taken, and interventions used.
Using the subjective and objective portions of the progress note, this section is used to assess the client and their presenting concerns within a psychological framework to help guide you in the next session – the Plan. You can include your interpretation and impressions about the client and/or their shared content here. For instance, you may use this space to track movement toward (or away) from a treatment goal and any possible risks of harm.
This space is intended to be used as a place to write your plans for moving forward, taking into consideration your assessment of this session’s content. It is a space for planning your next session, as well as a place to indicate longer-term plans that may need to be folded into the work at large. This can include something as simple as “continue therapeutic objective” or something more involved like an indication to adjust the treatment plan goals or tasks to accomplish in the next session.
The history and purpose of the SOAP Note
The SOAP format is one of the most common progress note formats, especially in internships where clinicians are just starting to learn how to write about their sessions. This is likely because it is just open enough to be flexible for content needs while still holding the clinician within certain boundaries.
It also has a long history in the medical field. The SOAP (originally called Problem-Oriented Medical Record) format was created in the 1970’s by Dr. Lawrence Reed. Its origins are from a medical model of healthcare and helped standardize the transmission of information between providers and between sessions. The format intended to capture in an organized way what is often complex and at times convoluted in nature. Though one of its main weaknesses is the difficulty of tracking change over time. Thankfully, treatment plans can help us do that, but that’s a topic for another time.
If you’d like to stick with the basics, with a tried-and-true structure, this may be the format for you. It does have its limitations and is quite simplistic, which I consider both a strength and a weakness. On the one hand, keeping it simple helps prevent overly complicated notes that are difficult to follow. While on the other hand, you’re missing out on some of the advancements made since SOAP first came into being, which we’ll explore in the next few posts.
Example of a SOAP Progress Note
SOAP Progress Note Template
If you’d like to use the SOAP Progress note template you see here, you can purchase it for instant download, or as part of a package with all forms, all client file forms, and all progress notes.
DA(R)P Progress Notes
Let’s start off by translating the acronym DA(R)P. It stands for:
I’ve included the R in parentheses as it is not always included in the progress note format. However, we’ll still go over it in this post. Now we’ll go over the note format, section by section.
If you recall in my last blog post on the SOAP Note format, there were two sections to describe a session: the subjective and objective sections. In this version of a progress note, both those sections are drilled down into one: the Data section. In this section, you’ll include both what you observed about the client and the session as well as the client’s subjective experience.
Like the SOAP note, in this section you will take the data from above and formulate your assessment of the session and client. This space is where you can reflect on the session content using your professional subjectivity. You can hypothesize about the client’s behavior or analyze their situation as it relates to their treatment goals.
This is somewhat of an extension of the Assessment section as it records the response of the client to your assessment and interventions. This can help inform treatment methods and goals by providing information about how the current methods are connecting with the client.
I’ll repeat what I wrote for the SOAP note Plan section, as this component is a common theme throughout all the progress note formats. This space is intended to be used as a place to write your plans for moving forward, taking into consideration your assessment of this session’s content. It is a space for planning your next session, but also as a place to indicate longer-term plans that may need to be folded into the work at large. This can include something as simple as “continue therapeutic objective” or something more involved like an indication to adjust the treatment plan goals or tasks to accomplish in the next session.
Purpose of the DA(R)P Note
The DA(R)P format can be especially useful in medical settings where a lot of data is collected all at once and needs to be recorded in the file. The argument for psychotherapists to use the DA(R)P format is that since clinicians aren’t often expected to collect a lot of objective information, merging the two sections into one Data section allows the clinician to simply write about the session. For that reason, it’s becoming more popular among psychotherapists.
One of my major concerns about the DA(R)P format is the opportunity it gives the clinician to overwrite. I saw this happen many times among the clinicians in training that I helped guide. When you have just one section to write both subjective and objective descriptions, it can easily turn into a long narrative rather than really focusing in on specific aspects of a session. That said, if a clinician can remain focused in their writing, I can see why the popularity of this progress note format is picking up.
Example of a DAP Progress Note
DA(R)P Progress Note Template
If you’d like to use the DA(R)P Progress note template you see here, you can purchase it for instant download, or as part of a package with all forms, all client file forms, and all progress notes.
DART Progress Note
Let’s start off by translating the acronym DART. It stands for:
Like the DA(R)P progress note format, this version also combines the two first sections of a SOAP note and drill it down into one: the Description section. In this section, you’ll include both what you observed about the client and the session as well as the client’s subjective experience.
Also like the SOAP note, in this section you will take the data from above and formulate your assessment of the session and client. This space is where you can reflect on session content using your professional subjectivity. You can hypothesize about the client’s behavior or analyze their situation as it relates to their treatment goals.
As opposed to the other progress note forms, the response section in this format is to record the therapist’s response, not the client’s. This space is to document the clinician’s initial response to the assessment and consider how they will respond to the situation. It is also the section in which a clinician explains their rationale for the interventions and approaches they take during a session.
I’ll repeat what I wrote for the SOAP note Plan section, as this component is a common theme throughout the progress note formats. This space is intended to be used as a place to write your plans for moving forward, taking into consideration your assessment of this session’s content. It is a space for planning for your next session, but also a place to indicate longer-term plans that may need to be folded into the work at large. This can include something as simple as “continue therapeutic objective” or something more involved like an indication to adjust the treatment plan goals or tasks to accomplish in the next session.
Purpose of the DART Note
You may want to use the DART note format if you’re more interested in recording your response to your assessment rather than your client’s response to your interventions and assessment. Of course, you could also include both sides of that coin and record both your responses.
DART Progress Note Example
DART Progress Note Template
If you’d like to use the DART Progress note template you see here, you can purchase it for instant download, or as part of a package with all forms, all client file forms, and all progress notes.
BIRP Progress Note
Let’s start off by translating the acronym BIRP. It stands for:
In this progress note format, the behavior section is for both subjective and objective data about the client and the session, much like the DA(R)P note format.
In BIRP progress notes, the focus of the session summary is more about what interventions a therapist used and a client’s response to them. The Intervention section is where you would describe what happened in session on a psychological basis, not just the content summary, but what you actually did as a therapist.
Following the Intervention section, is of course, the response to those interventions. You are encouraged to include what the client both did and said when encountering your intervention in session.
I’ll repeat what I wrote for the SOAP note Plan section, as this component is a common theme throughout the progress note formats. This space is intended to be used as a place to write your plans for moving forward, taking into consideration your assessment of this session’s content. It is a space for planning your next session, but also as a place to indicate longer-term plans that may need to be folded into the work at large. This can include something as simple as “continue therapeutic objective” or something more involved like an indication to adjust the treatment plan goals or tasks to accomplish in the next session.
Purposes of the DART Note
The biggest thing I love about the BIRP progress note format is that it encourages the clinician to really think about how to communicate what it is they are doing in session. One of the weakest spots for therapists, for new clinicians especially, is the ability to clearly communicate what their specific interventions in session were. I also find it important that the client’s response be recorded as it helps shape the picture of the client as well as how treatment with them should progress.
Personally, we know that we’re not just having a conversation with a client, we’re actively interacting with the client in trained and professional ways. How would you explain that to someone who has never been to therapy? Finding ways to describe your work not only helps legitimize it, it can also provide the clinician with a clearer sense within themselves with regard to their intervention strategies.
All that aside, I do think the biggest vulnerability for this type of format is that, on the surface anyway, it appears to rely heavily on behavioral observations. Unless you’re a behavioral purist, you’re likely bringing more than just behavior into consideration when working with a client. You’re also missing that key assessment space in this format.
It’s also good to know that using a BIRP format can be helpful in being able to organize the structure of your notes so that they answer insurance’s question of what kind of treatment you’re providing.
BIRP Progress Note Template
If you’d like to use the BIRP Progress note template you see here, you can purchase it for instant download, or as part of a package with all forms, all client file forms, and all progress notes.
Choosing a Progress Note Format
Deciding which progress note format is right for you
In this series we’ve looked at four different common types of progress note formats:
SOAP = Subjective, Objective, Assessment, Plan
DAP = Data/Describe, Assessment, Plan
DART = Description, Assessment, Response, Treatment Implications/Plan
BIRP = Behaviors, Intervention, Response, Plan
Now that you’ve read up on them, and seen an example of each one in action using a fictional therapist and her client.
How do you choose?
The first, and probably most important, factor is who may be reading your progress notes?
If you take Medicaid insurance, does the regional office require a specific format or information to be present? If your client is applying for SSDI and they may be requesting your files, you may need to be particularly careful what kind of format you use. And, of course, if you’re working in a clinic setting you should stick with the format that is presented to you as the clinic standard. Or if you’re working under a licensed clinician in a private practice internship, ask your supervisor their preferences and opinions.
What needs to be included?
Though ultimately it comes down to personal preference. If there isn’t a specific need for a particular format, you’re free to organize your progress notes the way you see fit. Just keep in mind the very basic information that should be in every progress note:
Header Information: containing the client’s legal name, the date and length of session, CPT code, and if there were any collaterals in the session with you
Session Description: what happened from an objective and subjective points of view.
Interventions and/or assessment: what did you do as a therapist to assist the client in moving toward the treatment goals
Plans: what the plan is moving forward after this session
Signature line with full clinician information
The California Association of Marriage & Family Therapist also suggests the following pieces of information are things you may also want to include in a progress note:
“Treatment modality used
Progress, and/or lack of progress
Modification(s) of the treatment plan
Clinical impressions regarding diagnosis, and or symptoms
Relevant psychosocial information
Safety issues; danger to self/others
Clinical emergencies/actions taken
Medications used by the patient
Treatment compliance/lack of compliance
Collaboration with other professionals
Referrals made/reasons for making referrals
Termination/issues that are relevant to the termination process
Issues related to consent and/or informed consent for treatment
Information concerning child abuse, and/or elder or dependent adult abuse
Information reflecting the therapist’s exercise of clinical judgment.”
Creating your own custom notes
If you’re feeling especially exacting about your progress notes, you can mix-and-match from what’s already out there and create a new combination of your own… as long as it meets the industry standard for what goes into a progress note and as easily understood by any other clinician that may read the note.
Above is an example of a hybrid note from my own private practice, also available for purchase and instant download, using our fictional therapist Mary Brown and her client Jane Smith.
ted to create a progress note that was both informative, quick to complete, and easily interpreted by another clinician. Let’s go through the sections together.
First there is the header information which will appear on every page of the progress note regardless of how many pages I type on. Regardless of what page in a file you’re looking at, you should always be able to tell who the client is, what the page is about, when it happened, and who the therapist is. We can talk about the legalities and ethics of that in another post.
I wanted to make my objective data easy to record by including a simple and shortened MSE and indication of any safety concerns with space to record relevant session content. I then created a list of my most common interventions based on my theoretical approach, with room for other interventions if needed. Personally, I did not include space for responses to my interventions as I would summarize that in the subjective report if it felt pertinent to the client’s treatment.
I also included space for an update on treatment plan progress on every progress note. If you think of a client’s file as being held together by a single thread of their story, I want to be able to present a coherent narrative where every part of the file is clearly connected to the rest.
I hope this series on Types of Progress Notes was informative and helpful for you in your practice. If you have a favorite type of progress note, comment below to share with us what it is and why. If you feel that I’ve left something out, or think I should’ve included another progress note format, you’re welcome to send me a message anytime to let me know.
I do hope you’ll consider following me as we continue together exploring the nuts & bolts of psychotherapy paperwork, some tips and tricks of the trade, and the ethics behind it all
Clinical Form Necessities
What should be on every form
It is my belief that you should create and fill out your paperwork as if every piece of paper could end up used as evidence in court. I know that sounds extreme but it’s the best way to cover your butt and make sure that your files are legible to anyone who might see them, whether that’s another clinician, SSDI, or even, yes, the court. With that in mind, what should be on every form to make sure it meets this standard?
One way to think about it is that with every piece of paperwork you should be able to easily figure out the following things:
·The purpose of the document,
Who the client is,
When the form was written, and
Who wrote it.
That’s not much if you think about it. All that usually entails is a form title, space for a client’s name, a dated signature or filled date, and your name with full license and title information. All the forms available to download on my site meet this criterion so you’ll never have to worry about whether you’re hitting this standard.
Now, what should be in every form is a different question altogether! Hopefully, I’ll be able to answer some of those questions as we continue with these blog posts.
Here are a few things to consider when setting up your e-mail signature.
Full Credential and License Information
In California at least, it is required by law that any time a clinician interacts with the general public, including a client, they must include their full name, credentials, and license number. If you are still in training and are under the supervision of a licensed clinician, you must also indicate that as well as include your supervisor’s information. See the next section for more information about that.
Here is an example of a proper and full signature name of a licensed clinician:
Mary Brown, LMFT (MFC12345)
Licensed Marriage & Family Therapist
As a licensed individual, you are not required to spell out your title’s acronym but ethically I think it’s a good practice. After all, most clients and the public have no idea what our acronyms mean.
Clinicians in training
Still speaking from California, one important thing to note is that if you are not yet licensed, you can’t just stick to acronyms. While you can include an acronym for your credentials, it must also be spelled out. For example, if you are an Associate Marriage and Family Therapist, you may use the acronym AMFT but it must also be spelled out. Here is an example of a proper and full signature for a clinician in training:
John Doe, AMFT (12345)
Associate Marriage and Family Therapist
Under the supervision of
Mary Brown, LMFT (MFC 12345)
Licensed Marriage and Family Therapist
This is because few people understand the difference between AMFT and LMFT and to avoid even the whisper of misrepresentation of your licensing status, you must make your title and credentials clear.
Working in a clinic or other organization
If you are a clinician working in a clinic or other organization, you must also always provide the clinic or organization’s name along with your own. Here is an example of a licensed individual working at a nonprofit clinic:
Mary Brown, LMFT (MFC 12345)
Licensed Marriage and Family Therapist
Nonprofit Clinic Name
You’ve probably seen those confidentiality notices at the end of a clinician’s email, but are those really necessary? Well, they’re not required by federal law per se (yet) but they are an excellent response to HIPAA’s requirement that a clinician take reasonable steps to help safeguard a client’s PHI (Personal Health Information). The HHS also provides the following recommendations:
“certain precautions may need to be taken when using e-mail to avoid unintentional disclosures, such as checking the e-mail address for accuracy before sending, or sending an e-mail alert to the patient for address confirmation prior to sending the message. Further, while the Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between health care providers and patients, other safeguards should be applied to reasonably protect privacy, such as limiting the amount or type of information disclosed through the unencrypted e-mail.”
Please note that while including a confidentiality notice helps you remain HIPAA compliant, it’s presence alone doesn’t mean your entire practice is HIPAA compliant. That’s a post for another day.
This is not a legal requirement by any means, but as the world progresses, it is turning into good practice. By providing your pronouns first, you are not pressuring trans and nonbinary people to share their pronouns if they are uncomfortable doing so. After all, many trans and nonbinary are not out in their day-to-day life due to the potential for discrimination and violence. Instead, it offers the opportunity for them to share in return if they wish to do so. It’s important that all clients feel welcome, and this is just one small step you can take to do that.
Here is an example of an email signature including pronouns:
Mary Smith, LMFT (MFC 13245)
Licensed Marriage and Family Therapist
It’s really that simple.
If you’d like to learn more about pronouns and why they’re important, check out this great article by Includr.
Responding to File Requests
You’ve just received a request for your client’s files. What do you do?
Well, that depends on who is asking and why.
The number one thing to keep in your mind at all times is your duty to protect a client’s confidentiality. Regardless of who is asking, your number one priority is to safekeep your client’s records unless given express permission to do otherwise.
The below examples are theoretical and if you are concerned or have any questions regarding the legal nature of any file request, please contact a legal professional.
As an example, let’s say a client is applying for Social Security Disability Insurance (SSDI) based on a mental health condition. In this case, the client should be informed that there is a strong possibility that the Social Security Administration (SSA) will request the client’s records. In which case, the client should sign a Release of Information (ROI) form to indicate their consent to share their files with the SSA. This may include a summary of treatment, diagnosis, and dates of sessions attended or it can include the entire medical record. It can even include both. It is up to your best clinical judgement to decide the balance between protecting your client’s confidentiality and what would be the most beneficial to their case. Most often you will be sending these records to the SSA directly. However, always keep in the back of your mind that there is possibility your client will see what you send.
Now let’s cover court subpoenas.
When first presented with a court subpoena for a client’s records, make sure to scrutinize it’s validity and refresh your knowledge of state and federal guidelines for your clinical discipline. If you have any doubts about the validity of the subpoena or questions about how to respond to it, seek legal counsel immediately. This includes if the subpoena is from out of state as they may not be sufficient to compel a testimony from you.
If you have determined that the subpoena is valid, and you have not been given consent by the client to release information, neither confirm that you are working with a client nor provide their medical records. However, don’t completely ignore the subpoena either. Simply reply with a statement indicating that you are unable to comply nor indicate whether someone is a client or not. Do not try to avoid being served. It’s unprofessional and unlikely to work anyway.
If the client is unaware that a subpoena has been issued, it is very important that you speak with the client about your legal responsibilities and their rights as a client to confidentiality. Describe in detail the process you will go through to protect a client’s confidentiality and at what point you will be legally forced to relinquish it.
You should also discuss with your client any information in their medical files that could be potentially clinically or legally damaging to them in court. If the client still insists on releasing their medical records, make sure to note in their file your concerns and seek additional consultation if necessary.
If a client does agree to allow you to share their medical records, and you do not have concerns about any potential negative clinical or legal repercussions, provide only the minimum information requested or needed that will satisfy the subpoena. This can include a treatment summary rather than the entire medical record if it would satisfy all parties involved.
If you’re releasing raw test data, be aware of copyright laws and your agreements with the publishers of such forms as well as state and federal laws. Consult with a lawyer if you have any questions or concerns about a conflict of interest between the copyrighted tests and a subpoena.
Lastly, remember that process (or “psychotherapy”) notes are not part of the medical file and should not be included in any file requests. In fact, they should always be kept separate from the medical file entirely.
The Zur Institute has a great article that goes into more detail on responding to court subpoenas and has gathered legal information from several sources to assist in your decision making.
What to include
As for what to include when providing a client’s records, it again depends on who is asking. If it’s the courts, follow the guidelines above.
For anyone else, there are a couple of guidelines: one legal and the other ethical.
Legally, you may only release information about a client that they consent to. Your ROI should have several options for what kind of information is to be released so that the client can tailor what they are willing to share. This can include all files, only a treatment summary, a list of session dates attended, medical conditions, etc.
Ethically, if a client is requesting a copy of their own files for personal use, it is up to the therapist to use their best clinical judgement to decide what and how to present that information to the client. Again, this depends a bit on the nature of the request.
Most often a file request comes from a client because they wish to transfer information to a new therapist or psychiatrist. In this situation, it is common for the therapist to offer to send either a treatment summary or the files directly to the other mental health practitioner.
If the client wants the files simply because they’re curious, it is usually best to first discuss the request with the client. There should be an in-depth discussion regarding the client’s interest in the files, their goals in seeing them, and what options are available to them. If the client still wishes to see their files, it is usually best to offer the client a summary of treatment instead of direct access to the files. If the client insists on seeing the files themselves, it is recommended that the clinician sit with the client and review them together so that the therapist can clarify any confusion and answer any questions the client may have.
And, of course, throughout this process document everything! You’ll want a clear paper trail showing that you’ve taken into consideration your legal and ethical duties to the client while also respecting relevant state and federal laws.
Subjective VS. Objective
When writing progress notes, the line between subjective and objective observations can be a bit blurred. Let’s break them down together.
In the dictionary the terms are defined as:
Subjective: relating to properties or specific conditions of the mind as distinguished from general or universal experience.
Objective: not influenced by personal feelings, interpretations, or prejudice; based on facts; unbiased.
Progress note implications
How does this translate to a progress note? Partly that depends on the type of progress note.
For instance, as I discussed in my blog post on DART notes, the subjective experience is focused more on the therapist than the client. However, most progress note formats focus on the subjective experience of the client. For that reason, I’ll focus on the term subjective as it relates to the client.
Subjective: relating to the specific experience of the client as distinguished from general, universal (objective) experience
Objective: the therapist’s observations of the client and their presenting issues without including their own feelings or interpretations
Since the subjective section of a progress note (usually) focuses on a client’s direct experience rather than our interpretation of it, it is often suggested that a direct quote about the presenting problem be used in this section of the note. For some clinicians, that’s where the subjective section ends. However, it can also include a brief description of the client’s subjective experience of the content session and/or their stated experiences of interventions used during session.
I’d first like to state that, of course, no one can truly be objective. That being said, the objective section of the progress note is intended to include information such as mental status exam (MSE) observations, observed responses to interventions, and factual information such as a brief description of session content without editorialization.
It’s important to remember that the SOAP progress note format was originally created for the medical field and so this is where the objective medical data, such as heart rate and blood pressure, was recorded. Therefore, translating it into a therapeutic narrative can be a bit more complex. That is one of the reasons that new progress note formats, such as DAP and BIRP, were created to adjust to this difference.
Creating Your Best Treatment Plan
Over the next two months we’ll be going over what makes an excellent Treatment Plan. We’ll break down the process of how to turn Goals into SMART Objectives, and in turn Objectives into Steps and Benchmarks.
We’ll also look at how to update your Treatment Plan as well as discuss best practices for how often a Treatment Plan should be updated.
But before we do all that, let’s talk a little bit about what a Treatment Plan actually is.
What is a Treatment Plan?
A helpful way to think about Treatment Plans is to imagine them as signposts along the road of your therapeutic journey. Sometimes along that journey you discover that you’ll miss a signpost and so must find a new one to aim for. Or perhaps you passed that signpost a long time ago and it’s time to look for the next. These signposts are your goals, and they should be considered only guides, not set in stone.
A Treatment Plan serves many purposes but the most important of which is that it provides clarity of direction in your treatment of a client. Even if your goal is maintenance and not necessarily improvement, having that focus clear in your mind and regularly refreshed can bring a clear intent to your sessions. This is especially important with long-term clients when goals can begin to get lost amidst the weeds of session content as time goes on.
Another way to look at a Treatment Plan, and a whole client’s medical record, really, is that it’s a story of the client’s therapeutic journey. A thread should be visible from Intake to Termination. In that way, each progress note should strive to remain attached to the Treatment Plan and the Treatment Plan in return attached to what is happening in sessions. In fact, just as you record overall progress on the Treatment Plan itself, I would recommend reflecting on the progress of each Treatment Plan goal in each session’s progress note.
Treatment Plans: Turning Goals into Objectives
The Difference Between Objectives and Goals
Let’s look at the difference between Goals and Objectives.
You can think of Goals as your overarching, big goal. It’s okay to be a bit vaguer in the Goal as it is an overall description of where you want treatment to go. Of course, you can make the Goal SMART as well (which we’ll go over next week) if you’d prefer. For our example, however, we’ll stick to the simple Goal of “reduce client’s anxiety.”
Now that we have our Goal, we should create up to three SMART Objectives that will guide the treatment toward that overall Goal. Here is the structure we will be using:
Now let’s translate that to our specific example:
As you can see, each Objective is tailored toward reaching the Goal. The question to ask yourself when creating your Objectives is, “What are three things a client should be able to successfully do to meet the Goal?”
You may have noticed that I keep referring to specifically three Objectives per Goal. That’s because any more than that and both you and the client can end up overwhelmed. Those excess Objectives then become unattainable, meaning they are no longer SMART. Again, we’ll talk more about SMART Objectives next week.
Treatment Plans: SMART Objectives
Let’s talk about what I mean when I say “SMART” objectives. This can, in part, be confusing because so often we see the term SMART connected with the generic term “goals,” which in a Treatment Plan has a different meaning.
When making Objectives for your Treatment Plan, you’ll want to make them specific, measurable, attainable, realistic, and time limited. In other words, make them SMART.
Let’s go over each section of a SMART Objective and come up with some examples.
What does it mean to make an Objective specific? It can be tempting to make a vaguer objective, such as “reduce anxiety” which is not very specific at all. Instead, ask yourself what does reduced anxiety actually look like. A more specific Objective would be something along the lines of “reduce panic attacks.”
The more overarching statement of “reduce anxiety” is better suited for a Treatment Plan Goal – the overall direction of treatment which we discussed last week.
Let’s take the above specific Objective and make it measurable. You want to reduce the client’s panic attacks but by how much? Are you aiming for one less panic attack a week? What measure of success works best for your client and this Objective? Avoid using vague measurements, such as “fewer panic attacks” or “less anxiety resulting in panic attacks” because neither of those allow you to measure success and create specific Benchmarks. (We’ll discuss what Benchmarks are later in this series.) Come up with a specifically measurable Objective that anyone would be able to decipher.
The Objective should be within the client’s control. For instance, if the panic attacks are a side effect of a medication, reducing them may not be an attainable Objective. (Hopefully, there aren’t any medications with panic attacks as a side effect! This is simply for the sake of the example.)
While Objectives should not be considered set in stone, you should aim to make them realistically attainable. For instance, it may be unreasonable to expect a client’s panic attacks to resolve completely in 3 months. Instead, focus on what seems realistic for the client and their Objectives.
This letter of the acronym is also sometimes referred to as relative, as in the Objectives should make sense in terms of your overall Goal. In our example, reducing panic attacks would absolutely be relative to our overall Goal of reducing anxiety.
Don’t leave your Objectives open-ended. Just as a signpost on a journey marks your progress, having an Objective end date allows you and your client to break down your Objectives into manageable chunks that can be measured and adjusted as treatment continues. It can be easy to get lost with an open-ended Objective, never quite sure if it’s truly attainable or needs modification.
Putting it all together
Having reviewed what a SMART Objective is, let’s put one together using the above examples.
Your overall Goal would be to reduce anxiety. One of your Objectives to meet that Goal would be to reduce panic attacks by one a week by (date 3 months from now). As you can see, the goal is specifically targeting panic attacks, measuring the reduction of panic attacks, is likely attainable and is certainly realistic and relative to the objective, within the timeline set.
Creating Benchmarks form SMART Objectives
Next week we’ll focus on how to turn Objectives into Benchmarks. In the meantime, if you’d like some assistance creating your own SMART Objectives, set up a consultation with me and we can create some together specifically for your clients.
Treatment Plans: Turning Objectives into Benchmarks
Now that we know what Goals and Objectives are, where and how do we translate them into action?
Just as we considered what Objectives would be needed to meet a Goal, it is time to consider what Steps or Benchmarks would need to be taken to meet an Objective. I tend to use both Steps and Benchmarks interchangeably but really a Benchmark is the end result of a Step taken to meet an Objective.
In my previous posts, we created a SMART Objective that stated a client would be able to reduce the number of panic attacks per week by one within three months of the goal creation date. Here is an example of some Steps that could be taken to meet that Goal:
Be able to identify and name panic attack triggers
Remain present to surroundings during panic attack
Implement self-care plan after panic attack
Format of Steps
The Steps for each Objective should be placed directly below that Objective. This is where you can transform them into Benchmarks. With each step, identify a date or specific and measurable sign that indicates progress toward achieving that step.
This can look something like:
Objective #1: Reduce the number of panic attacks per week by one within three months Due 3 months
Be able to identify and name panic attack triggers
Remain present to surroundings during panic attack
Implement self-care plan after panic attack
Remember to keep your Benchmarks specific as well, so that it is clear to anyone who reads it whether it has been met or not upon reassessment of the Treatment Plan.
Documenting Progress Status
As you regularly review your Treatment Plan, reflect on the Steps you listed. This will help you determine whether your Objective needs to be adjusted. Remember, not meeting a Benchmark does not mean you or the client failed! It simply means that a different Benchmark is needed. During this progress review is the time to make adjustments to your treatment signposts.
Documenting Progress in Progress Notes
As stated in a previous post, it is a good idea to track the smaller progress steps toward the Benchmarks in your progress notes. This helps keep the treatment record connected and focused. Here are some examples of possible progress indicators that you can use in your progress notes:
Progressing: there is movement toward the Objective
Variable: there is a mixture of both movement toward Objective and some movement away
Regressed: there is movement away from the Objective
Maintained: this is typically used for maintenance Objectives (such as ongoing harm reduction)
Not Addressed: content related to the treatment Objective was not addressed in this session
Resolved: the client has successfully met this Objective
Do this for each Objective and by the time it comes to review your Treatment Plan, it should be easy to go back through your progress notes and have a sense of where your client ended up in relation to their Benchmarks.
Treatment Plans: Putting It All Together
Now that we have a clearer idea of what Goals, Objectives, and Benchmarks are, let’s put them all together. First, let’s quickly review each section and add-in Interventions/Strategies.
Goals are your overarching end goals. These Goals can be either more generally encompassing, such as “reduce anxiety” or something as specific as “reduce levels of anxiety from a value of 10 to 5 within three months.”
These are the more specific Objectives in service to your overall Goal. This is where you answer the question of what specifically needs to happen for your Goal to be realized. It’s important to limit your Objectives to about three so as not to overwhelm your client or yourself. You also don’t want to dilute the focus of your Objectives by adding too many. Make sure your Objectives are SMART.
Benchmarks are the actionable steps to be taken to meet each Objective. These are the smaller steps that lead to the completion of the Objective.
It is important to also include in your Objectives the interventions and strategies you plan to use to meet the Benchmarks. This can be done in narrative form, a list, or even checkboxes of common interventions that you use, such as shown in the example below.
When we put all of these elements together, the structure looks like this:
Treatment Plan Form Example
And here is what it would look like on the free Treatment Plan form:
You’ll notice that this particular template does not give space specifically for Benchmarks, though you could just write them below your stated Objective. That’s because though they are incredibly useful, if you have a straight-forward SMART Objective, you may not need them. Though this template does not have the Benchmarks section, the other Treatment Plans available for purchase do include that space.
Treatment Plans: Regular Reviews
You know that Treatment Plans should be reviewed on a regular basis, but how often is “regular”?
What is “regular”?
My recommendation is that you revisit your Treatment Plans quarterly, or every three months. This allows enough time for some progress to take place while not too far out that you’re unable to adjust the goals and benchmarks as necessary.
Other times to update a Treatment Plan
There may be times when it makes sense to update a Treatment Plan sooner than even three months. Some examples of why this may happen include:
Your client shows signs of suicidality or homicidality and the Treatment Plan needs to be updated to reflect a clear focus on this with at least one of the Objectives. (We’ll discuss documenting suicidality and homicidality in a future post.)
It is clear that the Benchmarks need to be changed for the client to successfully meet them.
It becomes obvious that the Objectives or your Goal are unattainable, or not the best way to assist the client.
The client is not attending regularly enough to allow for the original Objectives and they must be shifted to focus on session attendance instead.
There are, of course, other reasons a Treatment Plan may be updated before a scheduled review but hopefully this gives you some ideas for why that may be. Except for the first item in the list (suicidality and homicidality), the other items may also wait for the three-month mark if you’d really like to. I would just recommend updating sooner to keep sessions focused and on track with the most relevant Objectives.
Maintenance Goals & Objectives
There are times when a Goal or Objective is aimed at maintenance and not necessarily forward progress. In these, and sometimes other cases an Objective and its Benchmarks can be continued through multiple Treatment Plans. For example, if a Treatment Objective was to “build therapeutic relationship by regular attendance of sessions, two out of four times a month,” and a client hasn’t been showing up those first few months on a regular basis, you can continue your Objective into the next Treatment Plan as it may be the bare minimum of attendance you would consider needing to build some level of therapeutic alliance.
Another example of a maintenance Objective could be, “continue to not self-harm for the next three months.” If the client is still at possible risk of self-harm in three months when it comes time to update the Treatment Plan, this is certainly an Objective that can be repeated.
Not meeting Benchmarks
As I’ve mentioned in a previous post, it is important to not think of missing Benchmarks as a failure on either you or your client’s part. It simply means that the Benchmarks, Objectives, or overall Goals should be adjusted to make them more realistically attainable for your client.
Treatment Plans: Using a Treatment Planner
You may have heard of Treatment Planners. There are certainly many great ones out there. The most extensive and popular series is from Wiley Publishers called “Practice Planners” (https://amzn.to/3pl8ZyD) – a series of 40 different treatment planner books that range from age group to specific clinical presentations.
The most basic Treatment Planners being:
The Complete Adult Psychotherapy Treatment Planner (https://amzn.to/3JeJNlc) *
The Adolescent Psychotherapy Treatment Planner (https://amzn.to/30QVdKK) *
The Child Psychotherapy Treatment Planner (https://amzn.to/3sqhVEP) *
These types of Treatment Planners are fantastic tools! I only have two cautions about them.
Know what you’re saying
These Treatment Planners provide a wealth of details on what to include in your Treatment Plan from a wide range of theoretical backgrounds. As I’ve mentioned before (paperworktherapy.com/blog/types-of-progress-notes-birp), many therapists have difficulty explaining what it is that they’re actually doing in sessions. These Planners can provide much of that language. Just make sure you fully understand what you’re saying if you choose to utilize their plans. You should be able to justify your Treatment Plan using your own words, not just those of the Planner.
Make it fit
Just because something sounds good on paper, doesn’t necessarily mean it fits your approach or a client’s needs. Don’t just copy and paste from the Treatment Planner, make it your own. Personalize each part of your Treatment Plan to make it the right fit for what you’re hoping to accomplish. And, of course, there are so many Goals, Objectives, Benchmarks, and Interventions that aren’t listed in these Planners that are available to you. Don’t get stuck thinking that you can only choose what’s on the page in front of you.
Treatment Plan Series Conclusion
And with this post, the series on Treatment Plans comes to a close. Though I’m sure that we’ll be revisiting aspects of the Treatment Plan in future posts. In the meantime, if you’d like to talk more in-depth about your Treatment Plans, set up a consultation with me. I’d love to work with you.
* note: I have an Amazon Affiliate account, which means I get a very small commission (1-10% of the product cost) if you choose to buy any of the products listed above through the links I provided.
We all know the importance of doing an initial intake assessment, but how many of us continue to reassess throughout our treatment with clients? What is a reassessment and what purpose does it serve?
The what’s and why’s
A reassessment is essentially a regular check-in with your client regarding any information that needs to be updated since their initial intake or previous reassessment. It can be something as simple as a shorter version of your intake form or you can make it a completely different form with its own relevant questions.
For those of you familiar with the Gottman's work, you know how important it is for couples to update their “love maps” – essentially the information they think they know about each other. The reason for this is because that information changes over time. To solidify and continue our connections, it is important that we check in regularly. The same is true for our relationships to our clients.
It can be easy to assume that our clients will tell us of changes in their life or update us on all of their current life circumstances. However, therapists are sometimes surprised to discover that in fact an important nugget of information went unnoticed because the client didn’t think it important or relevant to bring up in sessions.
While these reassessments can sometimes be done on your own as the therapist, I would strongly encourage you to go over each of the questions with your clients in order to trigger any thoughts or situations they had not thought (or avoided) to bring into session.
Creating a Reassessment
The simplest way to create a reassessment form is to take your intake form and change the questions to, “since our intake (or last reassessment) has X changed for you?” of “do you have any updates about X since the last time we checked in about it?”
Another approach to reassessment includes creating a new batch of questions that are relevant to your treatment. For instance, questions inquiring about the therapeutic relationship or treatment goals can be a focus of your reassessment. These kinds of questions can also be powerful tools in your ongoing treatment and clinical relationship.
I recommend that a reassessment be conducted every 6 months to 1 year after their first intake session and that reassessments continue on that schedule for as long as treatment continues. I’ve personally found that waiting an entire year can leave the client forgetting information because of how long ago it happened. I’ve found that every 6 months is ideal for capturing the most up to date and accurate information.
If you’d like to get started with a pre-made reassessment form, check out the one I have for sale. They are based on the Intake forms also available in my shop.