Psychotherapy paper work

[Creative-thinker]

Psy.D Student wondering about Psychotherapy session/ any session paper work.

Currently I am in the State of Cali. and I really can't remember the paper work steps. I know Intake is First, but during the session is when we do progress notes right ? I feel like I am over thinking this , can someone please list out the steps for beginning a session, during and after session paper work. Or even point me in the right direction of a video showing the types of paper work that needs to be completed first and during and after a session with a patient/client. It would be so helpful.

---

Members don't see this ad.

 

[avi.cenna]

A good starting point will be to learn about the difference between progress notes and psychotherapy notes. Progress notes are typically completed after the session (although if you are in a setting like integrated primary care you are often charting notes as you meet with a patient). Psychotherapy notes can be taken during or after session, or a combination of both. Each type of note serves a different purpose. I would encourage you to ask these questions to your professors as well because training/education on note taking and documentation should be a part of any Psy.D. program. Practicum supervisors will also be able to provide guidance around this. Good luck.

What are Psychotherapy Notes vs Progress Notes? | TheraNest

What is a Psychotherapy Note and how is it different from a Progress Note? Learn the definitions and HIPAA regulations for each in this post from TheraNest.

theranest.com

 

[Creative-thinker]

A good starting point will be to learn about the difference between progress notes and psychotherapy notes. Progress notes are typically completed after the session (although if you are in a setting like integrated primary care you are often charting notes as you meet with a patient). Psychotherapy notes can be taken during or after session, or a combination of both. Each type of note serves a different purpose. I would encourage you to ask these questions to your professors as well because training/education on note taking and documentation should be a part of any Psy.D. program. Practicum supervisors will also be able to provide guidance around this. Good luck.

What are Psychotherapy Notes vs Progress Notes? | TheraNest

What is a Psychotherapy Note and how is it different from a Progress Note? Learn the definitions and HIPAA regulations for each in this post from TheraNest.

theranest.com

Thank you.

 

[MCParent]

Your doc program should absolutely be guiding you through documentation in detail including things like documenting suicidal thoughts etc. It’s a very basic aspect of training. If you and others in your cohort don’t think it was covered enough in your pre-practicing classes that you’re familiar with it, you should probably bring that to the DCT as it’s a huge problematic oversight in training.

 

[erg923]

Psy.D Student wondering about Psychotherapy session/ any session paper work.

Currently I am in the State of Cali. and I really can't remember the paper work steps. I know Intake is First, but during the session is when we do progress notes right ? I feel like I am over thinking this , can someone please list out the steps for beginning a session, during and after session paper work. Or even point me in the right direction of a video showing the types of paper work that needs to be completed first and during and after a session with a patient/client. It would be so helpful.

Your prac site supervisor needs to go over this stuff with you and you will need to craft and format to their particular preference, as they really own the note in the end.

 

[AcronymAllergy]

This can vary pretty significantly across settings, and I would agree fully with those above who've said this is something your graduate program and practicum supervisor(s) should be instructing you on. As was noted above, broadly, there are progress notes (typically written after session, although some providers start working on them during session) and therapy notes (i.e., whatever notes you take during session about session content). Different sites (and different payors) have different rules/regulations about when and how progress notes need to be entered, what information needs to be included, etc.

In VA, for example, a progress note is typically all that's formally required after a psychotherapy session, but there are various reminders and other content that need to be included in the note. Sometimes a treatment plan also needs to be entered or updated. And if there is indication of suicidal/homicidal risk, there are additional assessments and documentation that may need to be completed.

 

[summerbabe]

Agreed with all of the above and want to encourage you to dialogue directly and explicitly about this with prac supervisors and professors.

Two more things to keep an eye on are timelines to complete psychotherapy documentation and have it reviewed and signed by your supervisor (which will vary by site) and what to do with physical copies of therapy notes, outcome measures, intake forms, etc (which again will vary by site).

When in doubt, ask ask ask!