Mental health therapists are tasked with helping their patients manage the symptoms of mental illness. But how can you tell if your patient is getting better? Do they understand what therapy is about? Do they trust you as a therapist? Understanding how to measure progress in therapy can be difficult, but it’s essential for improving patient outcomes and ensuring your therapeutic relationship is on track.
This guide will show you how to take notes on patient progress so that you can always keep an eye on how your clients are doing in therapy and make any necessary adjustments along the way.
Why Should You Track Patient Progress?
Tracking patient progress is one of the most important things you can do as a therapist. It helps you provide better care, and it also allows you to improve your practice in many different ways. This has been proven by research and experience, and many benefits come from tracking patient progress.
- You will learn more about your patients:
Tracking patient progress allows you to see how your patients are responding to treatment over time, which will help you make decisions about any changes that need to be made for them to continue seeing improvement. By reviewing their progress regularly, you’ll be able to spot patterns and trends that might otherwise go unnoticed until it’s too late.
- You may discover new things about yourself:
When reviewing a client’s record closely enough over time, specific patterns may emerge, revealing how well-suited you are for working precisely with this clientele. For example, if everyone who comes into your office ends up leaving with less than half an hour of work done each session, maybe it would be beneficial if you took some time off instead of working so hard so that you can make all those people feel better.
- Try to be fair with yourself:
Sometimes it’s easy to get caught up in what you want and forget what is happening around you. For example, without a note, you would certainly think your therapy is working for the patient. However, with notes, you can know whether or not what you think is true.
You can also share these notes with your patients. However, this open notes system is debatable. A patient cannot see your psychiatry notes according to HIPAA privacy regulations. However, if you want, you can share details of a particular session with the patients.
A survey of 92 experts from 6 countries concluded that open notes could have benefits and disadvantages. For example, patients can recall what was discussed during a session with the help of open notes, which is a benefit. However, while reading the notes, the patients may feel ashamed or insulted.
How to Manage Your Notes on Patient Progress
There are many ways to organize patient progress notes, including traditional paper files, computer databases, and apps. The best method for you depends on your preferences and which options are available in your clinic. If you’re just starting as a therapist or want to make sure your office has the best system for keeping track of patient progress, here are some tips:
- Keep notes in a file: This is probably the simplest way to go about it because all you have to do is write down what happened during each session and then add it into a folder with each client’s name on it when they come back next time.
You can also use this method if there is little office space where computers are limited. Just make sure everyone who works at that place knows where everything goes, so nothing gets lost.
- Email or text your clients: You can always email or text your patients after each session to let them know what they should do next. Just make sure to include any notes about the treatment and how long it will take for results.
- Use practice management software: If you want to go digital, tons of practice management apps can help you keep track of patient progress. Some are free, while others come at a small price, but they’re easy to use and make things much easier for everyone involved.
Practice management software has various features that allow you to chart patients’ progress. You can also share the charting details and notes with the patients. While many psychiatrists remain concerned about the effects of open notes, patients find them useful. Even research has not found any significant negative harms.
How to Take Notes on Patient Progress
Now that you know how to keep track of client progress, it’s time to turn your attention to the actual note-taking process. An important part of keeping up with patient progress is consistently and accurately documenting your observations in a way that makes sense for your practice.
Here are some tips for making sure you have everything necessary:
- Include verbatim quotes from sessions in addition to paraphrased summaries. This will help you remember everything important and relevant while preserving the original dialogue between you and the client.
- Record all significant details about each session. These details will help provide context for future sessions by giving both parties an idea of what happened previously so they can build on those experiences together moving forward.
- Be mindful of how much information per session feels like enough. Little detail may confuse when understanding precisely what went into each session. Too much detail can become overwhelming at times, too. A good rule of thumb is to use this same system every time without feeling overwhelmed by having too many things written down at once.
Writing appropriate details will also help get a gaze into what happened during the last visits of a returning patient. Patients can face many long-lasting negative effects during psychological interventions for mental health problems. In that case, having a detailed note will help determine what kind of effects were seen last time, which persist, and which don’t.
Conclusion
We hope this article has given insight into how mental health therapists measure patient progress. While it can be challenging to measure and track progress, it is an essential part of treating patients who are suffering from mental illness.
As we emphasized throughout our guide, therapists can use many different methods to track their patients’ progress. And while we’ve only covered four ways to measure mental health success for patients in therapy here, many other options are available. The important thing is that you find what works best for your practice so that you can provide effective care while still making sure everyone gets better over time.
