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What are clinical notes and how and why do we keep them?

by Dr Marianne Trent, Clinical Psychologist

This article has been amended from Episode 58 of The Aspiring Psychologist Podcast. If you'd prefer to listen to it then you can here. You can also watch it on YouTube here.

As ever, today we are thinking about something which is gonna be useful for you probably regardless of what your current role is. So it is clinical notes with talking about clinical notes and whatever role you're doing. If you're working with people, it's the 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 you know, 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 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 gonna 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 are 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 Apex Care Notes 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 are 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 maximise 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 gonna 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, may, 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, 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 cuz that relates to another client team, but like scrub that out. 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 hope you don't experience that, but you are 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 are an assistant psychologist, you also don't hold clinical responsibility, but if you are 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 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. So 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, you know, ensuring that we're sticking to safeguarding practices and reporting on anything that could potentially lead to a risk. And so one of my next 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 are justifying. So always be able to back up why you are 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.

So yes, what I do with my clinical notes these days is that I will document the session number and that might well include of how many planned sessions as well. So it might be eight of 20 for example, or if you don't know how many sessions are gonna 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 my own weakness. 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 N H S services or 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. 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's an open safeguarding case going on for the client that you are 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 homework to be done or things that the client said they're 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 a cl the client for the next session, I'm quickly up to speed with, with what we're what we are 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 E M D R that I've done, then there will be separate paper free paperwork now cause I've been using the remarkable two tablet that I really like. So I'll 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, it's called a remarkable two and it comes with 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, for example, for the first time yesterday I made supervision notes on it and then I can quickly send those as a pdf d 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 maximise 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 saves. 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 tight 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 and there's a hundred day quibble free returns as well. So if that is something you think might help you in terms of your organisation because you can save everything in separate folders and it's 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.

I would've loved a discount because I could not find any coupon codes anywhere when I was doing it! So I would say it's transformed 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 that 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 are all about the brevity, you know, cause we're all individually different, but it might be that you are very much led by what your current supervisor's requirements are.

What I've found is especially once qualified, 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 as 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. Cause 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 recruitment 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 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 C B T teaching that you can work through. We've got loads of stuff on reflective practise. 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 you know, whenever time suits you. For more information on that, do check out the show notes or check my socials and yeah, it will be available via my bio links. Those information about the membership do also please come along and join the free group on Facebook, which is the Aspiring Psychologist Community (free group). 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. I'm wishing you a lovely day. Whatever you are up to. Take care.

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