Now Modern Therapists Need to Document Every F*cking Thing in Our Progress Notes?!?

Now Modern Therapists Need to Document Every F*cking Thing in Our Progress Notes?!?

Curt and Katie discuss a recent citation from the California Board of Behavioral Sciences (BBS) to a therapist for cursing while in session. We explore: How do we document ruptures during the therapy session? Is the BBS over-reaching by controlling what therapists document? What are the best practices for note taking? All of this and more in the episode.

In this podcast episode we talk about appropriate documentation practices for modern therapists

As therapists it’s important that we take accurate notes. But what is important to include in the notes, and how much should we really be documenting?

Wait – Is it alright to use curse words in session?

• Therapists should be first and foremost aware of the client and their potential reaction.
• Note the therapeutic relationship with the client, their history, and how the client empowers themself when making language selections.
• If considering using casual language, consider the client’s vernacular.
• Follow the client’s lead when it comes to their language in session, including cursing.
• The BBS has no specific statute related to cursing or swearing.

What should modern therapists document in clinical notes?

• It is important to document any bold interventions or ruptures in the therapeutic relationship and repair attempts for ruptures.
• In note taking, it is important to follow the clinical loop: assessment, diagnosis, treatment plan, intervention, use of intervention, and the client’s reaction and progress.
• Your notes will be a balance of covering your liability and creating notes that help you remember the session.
• Therapists should consider documenting the use of any language that could be deemed not clinically appropriate, even positive statements like “I’m proud of you,” or “Yes, my dear.”

Does the California Board of Behavioral Sciences (BBS) outline what we should say in our notes?

• In the 300-page PDF outlining the statutes for LPCCs, LMFTs, LCSWs, and Educational Psychologists, notes are only mentioned 10 times.
• There is no mention in the statutes of what can be said and what can’t be said in notes.
• Some agencies and institutions will stress writing very little to ensure protection from liability, but as this citation showcases, this might not be best practice.
• The BBS wants to ensure the protection of clients and you might need to justify your words, just as you would justify the use of an intervention.
• This is a reminder that the BBS can and do look at therapist’s notes.

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