This was a question that a person on Quora asked. It is an important question based on the feedback that my clients have given me over the years. Here is how I answered it:
This is a great question because my clients have told me that they are very glad that I do actually take notes during all my client sessions. Why? Because many therapists write their notes after the session, many times leaving many details out what is going on with their patients. At least my clients have told me that they were not sure that their therapist cared about their case because they never could remember what was said from one session to the next. This has a negative effect on the therapy because the trust is never there from the patient’s point of view with this lack of knowledge of their situation on the part of their therapist who is supposed to be the one person that they can tell anything to and have it respected and recalled at least from their point of view.
It is because of the copious notes that I know exactly where we are in the treatment plan and what new information has come up that needs to either be integrated into the work or ratified for successful implementation of the guidance given during the previous session. Both of these actions make it clear to my clients that I am on top of their situations which allows them to feel respected and cared for in the manner in which they want their health care provider to demonstrate.
I know for those who are licensed there is a thought process as to what is necessary to put into their patient’s charts based on the professional standards and what they would prefer to omit for the confidentiality of the client based on if the case ever goes to court where the notes will be part of the record.
I am unlicensed and really do not have the same issues because of that situation. I have no problem recording whatever I feel I need is required to make sure that I never omit anything that needs to be acted on knowing that I really do not have a memory to help me and further realizing that our memories are by their very nature less than perfect recorders of what actually occurred during any event that we may remember.
Thank you for this very important question. Because I really do not believe that most mental health professionals understand the importance of taking decent notes could mean for their patients’ trust in the care that they are receiving – or not.
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