Private Practice Startup Podcast: Episode 168

Title: What’s Missing From Your Progress Notes
Date: January 11, 2020
Hosts: Dr. Kate Campbell & Katie Lemieux
Guest: Barbara Griswold, LMFT

Episode Overview

In this insightful episode, Dr. Kate Campbell and Katie Lemieux welcome Barbara Griswold, LMFT, an experienced therapist renowned for her expertise in insurance, billing, and documentation, to discuss the essential elements often missing from therapists’ progress notes. The conversation explores why effective progress notes matter, common misconceptions, compliance pitfalls, and actionable strategies to make notes thorough yet efficient. The episode combines practical instruction with many real-world examples, aiming to empower therapists to upgrade both their confidence and competence with session documentation.

Key Discussion Points & Insights

The Prevalence of Progress Note Problems

[02:43]

• Barbara’s survey of 500 therapists revealed only 5% felt truly confident in their notes if records were ever requested:

  “5% said that they felt confident in their notes if they were ever to be requested... So if you’re one of those folks listening and you’re thinking, ‘my notes, I really don’t feel comfortable, confident,’ you are not alone.” – Barbara Griswold [02:43]

• Many therapists receive conflicting or poor advice about notes, often from supervisors or colleagues, leading to bad habits and anxiety about compliance.

• Some even defend not keeping notes at all, with 2% of survey respondents admitting to this risky practice.

Why Progress Notes Are Often Neglected

[07:17]
Barbara identifies common reasons therapists’ notes fall short:

• Time pressure:

  “They’re a big time suck... what happens is we don’t write them and then we fall further and further and further behind.” – Barbara [07:17]

• Lack of formal training: Therapists often graduate without clear instruction on what or how to document.
• The myth of “less is more”: Some clinicians believe minimal notes protect client confidentiality, not realizing this can put both client and therapist at risk.
• Overconfidence in memory: Barbara emphasizes, “They’re not for you. They’re a medical record.” [09:03]
• Misconception about insurance:

  “The biggest myth that’s out there is ‘I don’t work with insurance, so I don’t need to keep good progress notes’ ...It has nothing to do with insurance.” – Barbara [10:29]

Essential Elements Often Missing from Progress Notes

[14:13]
Barbara’s “most missed” components include:

• 1. Specific Symptoms and Impairment
  Document not just the topics discussed, but relevant symptoms and how client issues impair daily life (e.g., anxiety, sleep problems, job troubles).

  “If somebody’s coming in... are they having anxiety about that? Depression? Are they losing sleep? You want the impairment... is it causing financial problems, occupational problems, not functioning well at work.” – Barbara [14:17]

• 2. Session Start and Stop Times
  Increasingly essential for compliance and audits.

  “Sessions start and stop times... we didn’t usually put from 1:05 to 1:55. And that’s what we need to do from now on.” – Barbara [15:07]

  This protects both billing accuracy and safety (e.g., during critical incidents).

• 3. Therapist Interventions
  Document what you actually did in session; many notes only reflect client dialogue or issues.

  “What did you do about that? This is supposed to be a record of medical service provided.” – Barbara [17:01]

  This includes both in-session interventions and homework/next steps.

• 4. Unusual or Administrative Issues Always note atypical events like fee negotiations, boundary issues, or client requests.

  “If they ask you something, like, ‘Hey, can we do a reduced fee?’ ... I’m going to be documenting a lot of that conversation.” – Barbara [18:34]

• 5. Objective Descriptions (Not Labels) Write like a neutral reporter, avoiding pejoratives or assumptions about client motives.

  “Always say ‘write like a journalist is in the room.’... Be documentarians, be journalists, and just describe what happened, but don’t use any pejorative language.” – Barbara [24:35]

Real-World Examples & Legal/Ethical Implications

[20:26]

• Barbara shares experiences from serving on her state Ethics Committee:
  • Abandonment complaints are common, especially surrounding abrupt or poorly documented terminations.

    “You have to handle referrals, coordination of care, but particularly endings, really carefully, and you have to document everything.” – Barbara [20:26]

  • Even billing complaints can morph into ethical investigations if proper records are lacking.

[23:29]

• Insurance documentation isn’t just for insurance! Even “private pay” or “personal growth” cases must be handled thoroughly, should records be requested.

Mindset Shift: Reframing the Purpose of Progress Notes

[25:24]
The hosts and Barbara encourage listeners to see their notes as integral to effective care rather than mere bureaucracy.

“For me, I’m a much better clinician when I write good notes... They help you give much better care. So, it’s not stupid paperwork. If it helps me give better care, then it’s very worthwhile.” – Barbara [25:37]

Additional benefits include improved client outcomes, more robust continuity of care, and the ability to demonstrate client progress at discharge.

Notable Quotes & Memorable Moments

• “If you didn’t document it, it didn’t happen.” – Barbara Griswold [18:17]

• “Your notes are far more important than you think they are and you should always write them as if an insurance plan is reviewing them or as if the client is reviewing them.” – Barbara [23:29]

• [Humorous highlight]:

  “I had one client come in and say, ‘Can I pay you in tomatoes instead of my copayment?’ That’s going to be documented.” – Barbara [19:11]

Practical Resources & Takeaways

• Barbara offers a free interventions list—a practical “cheat sheet” with sample sentences covering standard modalities (CBT, DBT, EMDR, etc.)—available via the show notes. [28:39]
• Listeners are encouraged to change their relationship with documentation, using it as a tool for better clinical care, risk management, and professional growth.

Timestamps by Topic

• 02:43 – Scope of the problem: therapists’ lack of confidence in their notes
• 07:17 – Why therapists neglect notes; common rationalizations
• 10:29 – Myths about insurance and documentation
• 14:13 – What’s actually missing: Barbara’s top five elements
• 18:34 – Documenting unusual events, administrative details
• 20:26 – Real ethics board cases: abandonment, referral/ending mishaps
• 23:29 – Write notes as if anyone could read them; neutrality in language
• 25:24 – Mindset shifts for paperwork; seeing notes as quality care tools
• 28:39 – Free interventions list and wrap-up

Episode Takeaway

Progress notes aren’t just a regulatory burden—they’re vital records of your work, protect you and your client, and can improve both clinical outcomes and your peace of mind. Reframe your approach: document proactively, thoroughly, and objectively—because, in both clinical care and risk management, if you didn’t document it, it didn’t happen.