Tuesday Top 5 (TT5): Elements of Notes

Okay, let’s dig into it. Process Notes. Charting. Progress Notes. DAP. SOAP. Yatta. Yatta. Yatta.

They are called a lot of things and they really are very important. Often, your job dictates how they are to be completed and in what format as well. Keeping notes for sessions is not only an ethical standard of our practice, it’s also an incredibly helpful tool if used correctly.

I admit it- I LOVE doing my notes. Not 100% of the time, and lots of times I’d rather be in a session. But I do really enjoy it. It helps me keep my client in the forefront of my mind when in session, if I take good notes before and after the session.

In a recent supervision meeting, my supervisor helped me come up with a great way to organize notes. I felt like there were 5 main elements in note-taking that were helpful for me. I’ve had to use a variety of note-taking systems in the past, and I feel like the following five elements can be incorporated into most narrative portions.

Tuesday Top Five (TT5):
Top Five Elements of a Good Note

  1. What interventions you utilized. 
    • My first sentence in my narrative note section usually starts with this
      • The therapist utilized songwriting……
      • “The therapist used active instrument playing…….
      • “The therapist created music paired with relaxation to……
    • Also, I don’t report on every single intervention within the session. I’ll pick the most note-worthy (so many puns there!) and highlight one or two for my note.
  2. Why they were used. 
    • This ends up being the second part of the sentence written above. Really, this is where we are explaining the awesome benefits of music therapy and not just saying what we did. If someone else read this note, number two is going to highlight the meat of the note.
    • For example,
      • “…. to support emotional processing related to grief
      • “……to improve bi-lateral arm coordination
      • “…….to reduce physical symptoms of anxiety
  3. How the client responded. 
    • Basically, did it work? If so, how do you know? This is where “as evidenced by” may come in to play. But everything in therapy isn’t “as evidenced by” is it?
    • I may use a “For example” or “For instance” with this section (see full note below).
    • For instance,
      • “The client responded to songwriting by creating over five phrases appropriate to the emotional content of the song, which led into a discussion of feelings such as worry, sadness, and hope.” 
      • The client responded to instrument playing by eagerly using left and right arms to reach and target paddle drums in 80% of opportunities presented.”
      • “The client showed physical signs of relaxation such reduced tension in face and jaw, more relaxed body posture, and slower rate of speech throughout the intervention”. 
  4. Why is this important for the client to experience?
    • This is my favorite part. Basically, why is music therapy supporting this and why is it important for them to experience this?
    • Let’s say
      • “Songwriting experiences continue to be important for the client as she has limited opportunities to create and discuss emotional aspects related to her medical illness”. 
      • “This client sometimes refuses to engage in physical therapy exercises without external motivation. Using motivating, client-preferred music, the client has been able to reach higher levels of success than without music therapy support.”
      • Client struggles with pain management and anxiety during active medical procedures. Music therapy interventions provide the client with distraction, reduced need to medication, and coping skills for future procedures.”
  5. What’s the plan? 
    • This is usually the easy part of the note. If things are working great, mine usually reads:
      • “Future sessions will continue to support these goal areas and utilize these interventions. “
    • If it’s not working, something like:
      • “Future sessions will continue to support goal areas but therapist will introduce new interventions to fully support client.” 

Since using this model, I have found that I am thinking through all of my interventions clearly, I spend less time taking notes, and I feel that my notes are more in sync with my sessions. When it all comes together, this is what it looks like:

“The therapist utilized songwriting to support emotional processing related to grief and emotions related to limitations of health.  The client responded to songwriting by creating over five phrases appropriate to the emotional content of the song, which led into a discussion of feelings such as worry, sadness, and hope. For example, client created the phrase “Deep down I feel the hope” after a musical prompt. Songwriting experiences continue to be important for the client as she has limited opportunities to create and discuss emotional aspects related to her medical illness. Future sessions will continue to support these goal areas and utilize these interventions. “

Hope this helps! Also, for you seasoned note-takers– did I miss anything? Would this work for you? Give me a shout out and let me know!

Kate

 

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