The Aspiring Psychologist Podcast - What are clinical notes, why do we make them and how?

Episode Date: January 16, 2023

Show Notes for The Aspiring Psychologist Podcast Episode: 58: How to writeclinical notesThank you for listening to the Aspiring Psychologist Podcast. Clinical notes have to be kept in clinical practice but what are they and why do they matter? How do we write and record them? Let me explain! Hope you find it a useful listen. I’d love any feedback you might have! The Highlights: (00:28): Welcome (01:35): What are clinical notes? (02:37): Timeliness (03:45): Finding the best way for you to do it (05:43): Redacting fun! (06:27): Clinical Responsibility (07:31): Supervisor and employer requirements (08:36): Details required by services and teams (09:40): Show your workings! (11:03): What to include (13:05): Risk (13:56): Modern ways to note take! (14:47): The Remarkable 2 device & $40 off if you fancy it! (18:38): Developing your own style (19:45): The Aspiring Psychologist Membership 21:00: Thanks, and Close Links: Get $40 off a remarkable tablet here: remarkable.com/referral/4LJU-DJD8  Grab your copy of the new book: The Aspiring Psychologist Collective: https://amzn.to/3CP2N97  Get your Supervision Shaping Tool now: https://www.goodthinkingpsychology.co.uk/supervision Connect socially with Marianne and check out ways to work with her, including the upcoming Aspiring Psychologist Book and The Aspiring Psychologist Membership on her Link tree: https://linktr.ee/drmariannetrent To check out The Clinical Psychologist Collective Book: https://amzn.to/3jOplx0  To join my free Facebook group and discuss your thoughts on this episode and more: https://www.facebook.com/groups/aspiringpsychologistcommunityLike, Comment, Subscribe & get involved:If you enjoy the podcast, please do subscribe and rate and review episodes. If you'd like to learn how to record and submit your own audio testimonial to be included in future shows head to: https://www.goodthinkingpsychology.co.uk/podcast and click the blue request info button at the top of the page. Hashtags: #aspiringpsychologist #dclinpsy #psychology #assistantpsychologist #psychologycareers #clinicalpsychology #mentalhealth #BPS #traineeclinicalpsychologist #clinicalpsychology #drmariannetrent #britishpsychologicalsociety #mentalhealthprofessional #gettingqualified #mentalhealthprofessionals #mentalhealthprofessional #mentalhealthprofessionals #workingwithpeople #supportatwork #personalandprofessional #worklifebalance #traineepwp #staffteam #mdt #qualifiedpsychologist #clinicalnotes #clinicalrecordkeeping

Hi there, it's Marianne here. Before we dive into today's episode, I want to quickly let you know about something exciting that's happening right now. If you've ever wondered how to create income that works for you, rather than constantly trading your time for money, then you'll love the Race to Recurring Revenue Challenge with my business mentor, Lisa Johnson. This challenge is designed to help you build sustainable income streams. And whether you're an aspiring psychologist, a mental health professional, or in a completely different field,

the principles can work for you. There are also wonderful prizes to be won directly by Lisa herself. And if you join the challenge by my link, you can be in with a chance of winning a one-to-one hours coaching with me, Dr. Marianne Trent. Do you want to know more? Of course you do. Head to my link tree, Dr. Marianne Trent, or check out my social media channels, or send me a quick DM and I'll get you all the details. Right, let's get on with today's episode. If you're looking to become a psychologist, then let this be your guide. episode. With Dr. Marianne Trent Hi, welcome along to the Aspiring Psychologist podcast.

I am Dr. Marianne Trent and I'm a qualified clinical psychologist. Thank you so much for tuning in and I hope you'll find today's episode really useful as ever. Today we are thinking about something which is going to be useful for you probably regardless of what your current role is. So it is clinical notes, we're talking about clinical notes and whatever role you're doing if you're working with people it's likely that there's some element of note taking. So in case you don't know what clinical notes are, I thought I'd give you a little bit of an overview of that to begin with. So when we are working with people, we have certain responsibilities and safeguarding actions that we have to take to keep people safe. But also it's useful for us

to be able to log and discuss what has happened in the contacts, especially if that involves risk. And that's so that other members of the multidisciplinary team can see what's going on if there's a crisis call, for for example or if there's other members of the team involved or if for example you were to go off on sick leave it would be useful to know what had been happening in your sessions. So the main function of clinical notes is similar to supervision is client safety and also your own protection for you to be sort of legally and professionally saying what has happened in a session. So how often do we need to be writing them? When do we write

them? How do we write them? Those are all of the questions we're going to be covering today. So in answer to how and when we write them it might well be that you need to follow the guidance laid out by whichever employer you're working for. So for example I think when I was working in an NHS trust most recently, they asked you to get it done within 48 hours, I think. I often found and still find that I am more likely to get it done within the appropriate timeframes if I do it right after the session. So I'm very much still a fan of a 50 minute clinical hour. And then I use the remaining 10 minutes to write my notes and get that done. I find that if I push it or delay it, or for some other reason need to dash out and do something else or get distracted or want a cup of tea, then yeah, it's less likely to happen in that timely manner within that day.

And of course, our memories are fallible. So I would say where possible, and obviously where your job plan allows, it's useful to get it done between sessions. And I guess thinking about how you write notes as well can be useful so it might be that you've got a trust phone or a trust tablet and that you can scribble your notes down on that between sessions it might be that you do paper notes still I know that some services still do that or it might be that you have to report your notes by entering them into a specific system. In the past, I've used EPEX, CareNotes and Rio. And yeah, you can't always access all of those systems from remote things like phones. But it might be worth saying that you might be able to, if you've got secure encrypted devices, such as, you know, a phone that's been given to you by your trust,

that you could use the note facility to write your notes in there so that you can access them later so that you're using the time you do have in a timely way so yeah don't do anything that's not trust compliant so if your trust doesn't allow you to do that then don't do that but I'm always thinking about ways that I can maximize the time that I'm doing so that I'm not repeating things or so that I'm using snippets of time that I've got. So yeah, have a look at your job, have a look at your job plan and see what might make that work for you. We're going to be going through some top tips for what to include in your clinical notes and how to do it in a way that makes them robust and user-friendly hopefully you know it's likely that in some cases no one will read them you know so if you hold

your own clinical responsibility then you know maybe no one will read them unless they get called by a court or they get requested by the client themselves and then you'll have the fun of redacting anything that you can't share with the patient which is where you go through with a big thick black marker pen anything that can't be shared so for example if they've been in a group and you've mentioned the actions of another group member even if you don't mention the group member's name you can't put that in because that relates to another client you've got to like scrub that out um so yeah redacting is very fun when you get a request for that either from a court or from the client themselves and you then have to look through years and years of notes that may not even be your own if the person has left the service. So I hope you don't experience that, but you probably are likely to at some point in your career. So be aware of that

term redacting, because it might well crop up for you. So yes, if you are a trainee listening to this, then it's likely that you don't hold clinical responsibility for your own client work yet. That would usually, as far as I'm aware, that would be held by your clinical supervisor. And similarly, if you're doing forensic or health, that would still be held by the qualified psychologist above you. So my first top tip is always speak to your supervisor. So if you're an assistant psychologist, you also don't hold clinical responsibility. But if you're a qualified PWP, I believe that you would hold your own clinical responsibility. So nobody would be needing necessarily to cross-check your notes whereas I have worked in services where my notes have needed to sort of be secondarily signed so

you will need to check in with your individual trust requirements and also what is safe and ethical practice for the role that you are in. Another reason that you need to speak to your supervisor is because all supervisors will have different standards and expectations for the way that they like to see clinical notes written and what feels good enough for them. So even if I reference my six different placements that I did on training, all of them had a very different vibe to them and very different expectations. So what was right for number one most certainly wouldn't have been right for number six. specifically was a psychodynamic placement and of course they believe in very detailed notes and also keeping something called process notes too as well as formulations so the process for clinical notes was very different than

it was for example when I was working with adults and similarly when we're working with children we might need to make even more thorough notes to be just ensuring that we're sticking to safeguarding practices and reporting on anything that could potentially lead to a risk. top tips is something that I only discovered when I was newly qualified and that is if you are making a decision or if you have had support to make a decision then you should record that in the notes but you should also justify how you've come to that decision. So if that's as part of a multidisciplinary team meeting or discussion with your supervisor, you need to be evidencing the rationale for that decision making process. Because if you just write what the decision is, then it's a bit ambiguous about how you got there. But it's a bit like in maths when you were doing maths at school if you show your workings then it's clearer in a court of law should you need to justify what you're justifying so always be able to back up why you're suggesting something if you are

asked to do it but I sometimes think if I was called to a court and the judge asked me to justify something, unless it's written down, I can't. I can't just say, well, I was holding that in mind because that's not legally robust. So anything related to risk and decision making needs to be in your notes. So let's take a brief break here and then I'll be back along with my next top tips. from so many things that you can try the aspiring psychologist the aspiring psychologist welcome back uh thank you for sticking with me i hope you love the jingle so um yes what i do with my clinical notes these days is that i will document the session number and that might well include um of how many planned sessions as well so it might be eight of twenty for example once you don't know how many sessions are going to be I

would just write what the session number was and obviously whether it was attended or not also I would document whether it was attended on time and if not what what the reasons for that were might have been my own absence my own leagueness but yes it doesn't happen so much in private practice I don't think it's happened ever actually but certainly when I was in NHS services or other other employed services sometimes it was my responsibility that I was I kept a client waiting so I would kind of go through the main points but not in an exhaustive fashion so the main points covered and if there were any pertinent discussion points within that I would

put those in almost as a bullet point kind of section so we discussed yada yada yada you know that sort of thing but it was not it's not exhaustive um i do not work in a psychodynamic way currently so it's not everything i can remember about a session of course we need to make sure that we've got any elements in there that are related to risk or safeguarding so if there there's an open safeguarding case going on for the client that you're working with or someone immediately in their life that they are kind of responsible for,

then we need to be having that discussion and revisiting that and documenting any changes with relation to safeguarding or any updates in there. And similarly, if there's any elements of risk and any elements of sort of risk taking, then you need to be evidencing that and you need to be evidencing if there's a plan to manage that risk, which might well link back to any care plan or risk plan that's been done either with you in conjunction with you or with other members of the team or psychiatry. I will also cover any agreed action points so if there's homework or own work to be done or things

that the client said they were going to strive to do then they will be they will be noted down so that if and when I need to review those before seeing the client for the next session I'm quickly up to speed with with what we're what we're striving for what we're aiming for and what we'd agreed and it's not necessarily as a way of you know checking up on them but it's thinking about you know I wonder how how you got on with that and what's that been like for you and is there anything you know new or different since we met last time that can be a really nice way of exploring that area without making people feel like they're being checked up on and then I would write the next session date and that's pretty much it so they're not super long like I said they're 50 minute sessions.

And if there's EMDR that I've done, then there will be separate paper free paperwork now because I've been using the Remarkable 2 tablet that I really like. So I will talk about that in a moment. But yeah, there's extra paperwork there. So I would also report that separate EMDR paperwork has been made and will be added to the file. So let's have a little think about this remarkable tablet that I've got. So I've used it to plan today's podcast episode. You might not have heard of a paper free tablet. So it's called is called a a remarkable two and it comes with um actually i don't think it does come with it i think you have to buy it separately so i bought this pen separately and it's got a nice little rubber on the end and you can rub stuff out but what i like about it

is that so for example for the first time yesterday um i made supervision notes on it and then I can quickly send those as a PDF via email or through a few clicks of the button to send it to myself. And then I can just upload that to the client's clinical notes and make a note that the supervision notes have been have been added so again you'd need to check what was trust compliant but I'm always thinking about how to maximize the time that I've got so I found that I like supervision I enjoy that process but then having to write separate notes for it afterwards especially when I'm now in private practice I don't get paid for that time just felt a bit frustrating so that's where I'm really liking this paper free tablet because everything happens within the session and then I it just saves automatically and then I can just do it with a quick few clicks and save so if you think that might work for you then you could well discuss

that with your supervisor or your manager. I did try initially to try and get on board with that happening with an iPad but I could not get it to do what I wanted to do and for it to remain as functional. So what I like about the Remarkable is that I can go back into the notes, they can stay handwritten or I can have little bits appear in typed text to help it stand out more. I can draw my family trees on there, which I really like to do. So yeah, when I was buying my Remarkable, I couldn't find any discount codes

and that was frustrating to me. But I have got a $40 off code if you do want to try it out. There's 100 day quibble free returns as well so if that is something you think might help you in terms of your organization because you can save everything in separate folders and it all can be password protected and all of that jazz so yes if you think that's something that would be useful then do think about yeah getting yourself a tablet and there will be details in the show notes or you can send me a dm

if you want that coupon code to get 40 off which i would have loved because i could not find any coupon codes anywhere when i was doing it so i would say it transforms my practice and i'm going to look at whether i can implement it into my clinical notes with clients. The only difficulty being is I don't currently write clinical notes in sessions because I find it sometimes takes away something about what I'm doing with the client so I'd need to think quite carefully about the way that I do that especially as I'm being paid for that time by the client. But yeah, I want to think about how I can do that in a way that suits my needs and doesn't take from

the client and their session. So yeah, I would love any thoughts you've got about how you do your clinical notes and whether you found this episode useful, whether it's raised any thoughts for you really whether you are the sort of person that likes to write really long notes whether you're all about the brevity you know because we're all individually different but it might be that you're very much led by what your current supervisor's requirements are what I found is especially once, you can take the bits from certain jobs or placements that you do like. And anything that doesn't work for you doesn't sit. You can leave behind when you leave. And then so long as you're following the guidance of any new supervisor until you're qualified, you can pretty much do what you like, what works for you. Because you're allowed to develop your own personal style and flair as well

so if you would welcome more advice and guidance about so many different topics we've also got stuff coming up in the membership about logical and deductive reasoning which i know is a big part of some declinci testing processes so we've got a session happening on that to help develop confidence so by the time you listen to this it will have happened but you'd be able to access that on replay if that is something that you feel would be useful for you and to develop your confidence and competence in that area. We've also got loads of other stuff in there. We've got seven or eight months worth of CBT teaching that you can work through. We've got loads of stuff on reflective practice.

It's just a good place to hang out. It's a really, really nice supportive group of people so do check out the aspiring psychologist membership which you can join for 30 pounds a month which also gets you access to the back catalogue and you can leave um you know whenever time suits you for more information on that do check out the show notes or um my socials and yeah it will be available via my bio links there's information about the membership do also please come along and join the free group on facebook which is the aspiring psychologist community brackets free group i think he says my name and so on dr marianne trent or come and connect with me on all of my social channels I am now Dr. Marianne Trent and I love helping you celebrate your wins and hearing what you think to the

content that I produce so again thank you so much for listening thank you for being part of my world and wishing you a lovely day whatever you're up to take care if you're looking to become a psychologist then let this be your guide with this podcast at your side you'll be on your way to being qualified it's the aspiring psychologist podcast with dr marianne My name's Jana and I'm a trainee psychological well-being practitioner. I read the Clinical Psychologist Collective book. I found it really interesting about all the different stories and how people got to become a clinical psychologist. It just amazed me how many different

routes there are to get there and there's no perfect way to become one and this kind of filled me with confidence that no I'm not doing it wrong and put less pressure on myself. So if you're feeling a bit uneasy about becoming a clinical psychologist I'd definitely recommend this just to put yourself at ease and everything will be okay but trust me you will not put the book down once you start.