Written with love by Lacey Andrews, Psychologist & Board Approved Supervisor

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Taking notes is hard. I remember when I was a Provisional Psychologist working at TAFE, NSW taking up to an hour to write complex notes. Thank goodness I had the time to do so. However, when I moved to private practice, taking this much time was simply not possible – having only 10 minutes to write notes between clients. I essentially had to relearn how to do it. What is important information? What language do I use to document it? Were some of the questions asked myself.  These questions, as well as others, have inspired me to write this blog. I hope you find it helpful and time saving!

In this blog:

• Identifying Important Information
• Clinical Language 
• Writing For An Audience 
• The AI Shortcut 
• Managing The Admin Load 
• Conclusion

Identifying Important Information

I remember reflecting on this when I was training. I still reflect on it now. How do I identify what is important in a session. Isn’t it all important? 

Well the answer to this questions is, yes it is all important AND at the same time you do not have to write it all down.

Because a clinical note is not a transcript. It’s purpose is to record the service provided to the client, and should include “accurate and current information about the planning, implementation and review of the services provided” according to the APS Professional Practice Guidelines on Record Keeping.

So what does this actually mean in practise? I find it helpful to think of a note as a way to connect the client’s history, with current intervention in a way that informs future treatment. So, when I look at my own notes I will see:

• A brief Mental Status Exam 
• What the client reported to me in the session relevant to their mental health 
• What I did about it – the intervention/s
• The client’s response to the intervention
• Depending on where we are in our sessions treatment planning/case formulation elements, and even notes about consent ( especially in the first session where I explain privacy and consent). 

This is my framework for identifying important information. If it doesn’t fit into these “boxes” I reflect on it’s purpose and does it really need to go into the note? 

Clinical Language 

It almost goes without saying, a clinical note is not a casual affair. And that’s not a bad thing. We are providing a professional service after all! The beauty of clinical language is that, once you get the hang of it, it actually provides a structure that helps you write your notes more efficiently.

Think of it like a shorthand that does the heavy lifting for you. When you use “anchor phrases” to start your sentences, the information that follows automatically falls into place.

For example:

• “The client reported…” (Their subjective experience)
• “We discussed…” (The collaborative work you did)
• “The client said words to the effect of…” (When you want to capture the essence without a direct quote)
• “The client appeared…” (Your objective observations)

Using these phrases isn’t about trying to sound stuffy or overly formal. It’s actually a really practical way to separate what the client told you from what you noticed as a clinician. It keeps your record-keeping clean and objective, which saves you a lot of mental energy in the long run. 

Writing For An Audience 

Often, no one else but you will ever see the notes you write. However, it is important to keep in mind that you are actually writing for an audience when you construct them. It is the client’s legal right to request their case file, and you need to supply it to them in a reasonable timeframe unless there is a very good reason not to (such as if accessing the records would pose a serious threat to life).

And of course, there’s always the possibility that your notes could be subpoenaed in a court case!

This is all the more reason to use clinical, professional language and to be mindful not to over-include information that isn’t relevant to the service you are providing. When you write with the audience in mind, you tend to stay objective and focused on the “why” of the session, which protects both you and the client.

The AI Shortcut 

You would have heard that there are now several AI products that support healthcare professionals, including Psychologists, to take notes. I have tried a couple of them out, and they all work on the same principle – the audio record the session and use an algorithm to generate a clinical note. 

There are a couple of things to remember here, if you choose to use them in your practise: 

• Get client consent to use them in writing before using them, and at least verbally after that every session it is used 
• Check EVERY note generated for inaccuracies and hallucinations 
• Keep abreast of where the AI note is generated and where it is stored. I personally delete the transcript promptly after every sessions, and once I transfer the note to my practice management/clinical software I permanently delete the generated note too

In saying that, I have found the AI I use to be quite accurate and needs minimal editing. And once I got the hang of it I found it to be quite the time saver! 

Managing The Admin Load 

So, if you use AI note taking software this will likely help. But what if you don’t use it? How will you manage the Admin load of manually taking notes? Here are a few ideas. 

• Experiment with bulk note-taking. If you write up your notes in the 10 minutes between sessions and find it is not working for you, have a go at saving your notes to do in bulk at the end of the day. Or, if you’re already doing this, experiment with taking your notes in the time you have between sessions. 
• Instead of writing full paragraphs for every MSE (Mental Status Exam) or risk assessment, create a shorthand checklist.
• If you work via telehealth, sometimes staring at the screen for 8 hours makes typing feel like a chore. Try jotting down key “anchor words” or quotes on a physical notepad during the session. These act as memory triggers so that when you sit down to type later, you aren’t staring at a blank screen trying to remember the “vibe” of the conversation.
• Don’t wait until the session is over to start the note. Do the administrative part of the note (date, time etc) before the session starts 
• Create a template you use for all notes where you use as many check boxes as possible. It can help reduce cognitive load – for example, by having your most common observations like MSE elements, risk levels, and intervention types already laid out, you can simply tick the relevant boxes as opposed to writing it out in full! 

Conclusion

I hope you have found the information in this blog helpful. If you have any questions or require more support around note taking or any other topic related to your Provisional Psychologist journey please do not hesitate to email me at info@sparkpathpsychology.com.au, or use the contact form here. 

References

APS Professional Practice Guidelines on Record Keeping

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