NCE Study Guide Podcast
Host: Glenn Ostlund
Episode: Patreon Deep Meditation Module 15 of 28: Clinical Documentation and Case Notes
Release Date: October 7, 2025
Episode Overview
This episode, part of the Patreon “Deep Meditation” series, merges relaxation techniques with essential NCE content, focusing on clinical documentation and case notes. Host Glenn Ostlund uses a meditative, soothing tone to guide listeners through core documentation formats (SOAP, DAP, BIRP/BURP), as well as best practices around tracking risk/protective factors, crafting diagnostic justifications, and composing ethical referral reports. Designed to embed key exam knowledge deeply through mindfulness and repetition, the session also emphasizes the humanity and ethical responsibility embedded in clinical paperwork.
Key Discussion Points & Insights
1. Purpose and Heart of Clinical Documentation
- Documentation is more than a requirement; it’s a testament to therapeutic work, evidence of presence, and care for clients.
- “Imagine each case as a footprint, evidence that something meaningful happened in session. A trace of your presence, your care, your clinical mind at work.” (03:38)
- The structure of notes serves continuity, accountability, client care, and sometimes, professional/legal protection.
2. Overview of Major Note Formats
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SOAP Notes (Subjective, Objective, Assessment, Plan):
- Most common, structured for clarity and momentum in care.
- “It starts with the client’s own voice, subjective, then grounds what was observed—objective—synthesizes the meaning—assessment—and ends with a clear direction forward—plan.” (05:10)
- Ensures each session documents the client’s experience, clinician observations, interpretation, and next steps.
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DAP Notes (Data, Assessment, Plan):
- Streamlines SOAP; "Data" incorporates both subjective and objective information.
- “The data section includes both subjective and objective material. The assessment instills your clinical insight. The plan carries momentum, ensuring continuity.” (07:32)
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BIRP/BURP Notes (Behavior, Intervention, Response, Plan):
- Focus on action, suited for tracking specific interventions and client responses.
- “What did the client do or say? Behavior. What did you offer? Intervention. How did they respond? Response. What’s next? Plan.” (09:49, 14:13)
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Emphasis: The format matters less than the integrity, clarity, and ethical soundness of documentation.
- “Each format is a tool. What matters more is your integrity, your attention to detail, and your ability to write notes that are concise, clinically sound, and ethically grounded.” (10:14)
3. Risk and Protective Factors
- Clinical notes must document both risk (e.g., suicidal ideation, trauma history) and protective factors (e.g., support systems, coping skills).
- “Risk and protective factors must be noted with care. Whether the client expresses suicidal thoughts, has a plan, or presents with a history of trauma. But also look for what steadies them—support systems, coping skills, spiritual resources. Protective factors are as vital as risks.” (11:06)
4. Diagnostic Justification
- Goes beyond listing symptoms; must connect client report, clinical observation, DSM criteria.
- “A diagnostic justification is tracing the thread between what the client reports, what you observe, and what the DSM outlines. This is a place for clinical reasoning, not guesswork.” (13:52)
- Justifies chosen diagnosis with evidence, protecting clinician and client should questions arise.
5. Referral Reports
- When referring a client, documentation should remain professional, succinct, respectful, and confidential.
- “Your referral report should be respectful, succinct, and professional. Include only what is necessary. Maintain confidentiality. Invite collaboration.” (14:29)
6. Ethics, Accountability, and Compassion in Documentation
- Notes are not just for insurance or compliance.
- They promote continuity of care, clear communication, and can serve as a clinician’s protection.
- “Remember, documentation is not just for insurance. It is for the client, for continuity, for accountability. And sometimes it's for protection—yours and theirs.” (15:37)
- Even paperwork holds meaning, memory, and a reflection of the clinician’s care.
- "May your documentation be steady and sincere. May your language be clear and kind, and may your presence always come through on paper and beyond it, even long after this sound fades." (16:21)
Notable Quotes & Memorable Moments
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On the Essence of Documentation:
- “Let your notes be offerings, quiet testaments to the work that unfolds in the space between words. You are not just recording data, you are witnessing change, tracking safety, anchoring insight.” (16:14)
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On the Personal Nature of Note Writing:
- “Yet even in the paperwork there is heart, there is compassion, there is meaning, there is memory.” (16:12)
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On Professional Responsibility:
- “Each format is a tool. What matters more is your integrity, your attention to detail, and your ability to write notes that are concise, clinically sound, and ethically grounded.” (10:14)
Timestamps for Key Segments
- [03:38] – The meaning and purpose of clinical documentation
- [05:10] – SOAP notes explained
- [07:32] – DAP notes structure
- [09:49, 14:13] – BIRP/BURP notes detailed
- [11:06] – Addressing risk and protective factors
- [13:52] – Diagnostic justification: connecting the dots
- [14:29] – Referral reports best practices
- [15:37] – The ethical and practical reasons behind documentation
- [16:12]-[16:21] – The heart, meaning, and humanity in clinical notes
Final Thoughts
Through meditative instruction, Glenn Ostlund underscores that clinical documentation is a vital, compassionate, and ethical cornerstone of counseling. He emphasizes the importance of clarity, honesty, and attention to detail across all documentation forms—reminding listeners that notes are a reflection of both professional standards and the authentic care offered to clients. Every format—SOAP, DAP, BIRP/BURP—serves this higher purpose when grounded in integrity and human connection.