Therapy Notes

The dreaded session notes... we all do them, but how can we really ensure they are accurate, ethical, and ultimately clinical? 

After all, the note is in place to ensure clinical necessity was at the root of each session. So how do we prove clinical necessity? 

No...we can't say we played Uno the whole session and it was necessary for the client's mental health. But we CAN describe the reasons behind the game! We focus on distress and frustration tolerance, communication skill building, social cues, etc. Once you find your voice, the notes align and you will be well on your way to feeling sound in your documentation.