Article from: Counselling Australia Journal: Volume 23: Number 1 – Autumn 2022
It is extremely important that professional supervisors have a good knowledge of what is appropriate and what is not with regard to note-taking. Not only do professional supervisors need to be aware of their own notes, but they also need to ensure their supervisees are keeping appropriate notes. Notes can be subpoenaed and, therefore, if they are not correctly written, the conduct of the supervisee and their professional supervisor will be brought into contention. Notes need to be legible, concise and accurate (Despenser, 2004; Presser & Pfrost, 1985).
For the supervisee, accurate notes are useful when debriefing with your professional supervisor, particularly if a difficult case was experienced several weeks before your professional supervision. Reading your notes the day after seeing a client can also be enlightening – you may find you have been judgmental, or your own belief system is interfering with your objectivity. Read notes critically, but do not change them; learn from them (Despenser, 2004; Presser & Pfost, 1985).
Taking notes is a contentious issue. Should you take notes, and if so, how much should you document and how should you reflect statements? What words are appropriate and what words will leave us professionally vulnerable? There is no real answer; but consider: will your notes be adequate and not incriminating if you are called upon by a court to divulge them, and will your client sue you after reading them? It is a good idea for professional supervisors to critique their supervisees’ notes, particularly those of new supervisees.
Clarity in documentation
The following is an excerpt taken from the American Counseling Association and written by Robert W Mitchell, ACSW. This document, entitled Documentation in Counseling Records, is relevant for any professional who is required to take notes (Mitchell, 2000; see also Armstrong, 2006).
Mark Twain once said to would-be writers, “As to the adjective, leave it out.” His words have meaning to us today. He meant that when you write an adjective, for better or for worse, you give an opinion. Adjectives must be carefully chosen, or even replaced, if language is to be clear and precise.
Examples of the need for clarity and precision are the focus of this article. Your written words are the only record of a session you have with a client, and those will count for nothing, for your agency’s purposes or in a courtroom, if you have not written them down accurately.
Let’s take an example: The sky is blue … no, the sky is generally blue … no, the sky generally appears to be blue… no, in some parts of the world, what is generally thought of as the sky sometimes appears to be blue. We sometimes make things harder on ourselves when we go to extremes. All we need to say is the sky is blue. In many instances, the work we do is simple and very straightforward; we don’t need to mystify it with complicated or confusing words.
Here’s another example: Jerry is exhibiting signs of depression … Jerry is depressed. These sentences are grammatically correct, yet I am unsure what exactly is meant. An attorney would have a great time with either of those statements, saying the writer was judgmental, prejudiced. The client was simply a quiet, unassuming person whose behaviour produced unwarranted and false conclusions. To eliminate that possibility, all you need to do is add a simple clarifying phrase. If Jerry is depressed or showing depression, add something like ‘because he lost his job’. If Jerry is repressing his emotions, add ‘by not answering questions and by changing the subject’. What clues tell you Jerry is depressed? Add ‘he said he has not been able to eat or sleep and is concerned about the crying spells’. Now your conclusions are supported with specifics.
Let’s consider more examples:
- A favourite but inadequate phrase in records involves ‘negative attitude’. Again, that is too vague and too judgmental. To make it clear, write something like: ‘learn to discuss problems instead of throwing things’.
- A frequent goal is ‘improve hygiene’. That’s too vague because it doesn’t tell you enough of a story. You must be specific. How about: ‘brush teeth and shower each day’?
- Don’t write: ‘learn to become more independent’. What does that mean? Set up a business? Leave a husband? The specific goal could be: ‘get up in the morning and report to job on time’.
- ‘Increase self-esteem’ is another favourite goal, but it’s difficult to really sink one’s teeth into such a phrase. How about: ‘will not be critical of self or personal decisions about disciplining children’. See the difference?
- The record may read: ‘client participated in chalk talk’. What does ‘participated’ mean? Will every reader understand that a ‘chalk talk’ in this instance is a chemical dependency lecture? Did the client talk? Cry? Take a swing at another client? Or at you? Someone can participate in an active or a passive way. So one word doesn’t tell much. To clarify ‘participate’, add for example, ‘client revealed examples of how he had fooled himself about the increasing use of drugs. He reported denying the importance of wife’s complaints. The group encouraged his willingness to open up.’
- Since part of our topic concerns communication, let’s take the phrase ‘communication problem’. Again, what does this mean? Why not list the exact problem; for example, ‘stuttering’, ‘speaking too fast’ or ‘talking around the subject’.
- Is your client withdrawn? How do you know that? Write instead, ‘Suzanne is withdrawn as evidenced by the fact that she spends all her time in her room and refuses to even eat meals with her family.’
- To characterise someone as ‘aggressive’ is not enough. Does the client fight? Push? Scream? Kick? Do not leave room for interpretation. If the client described eventually takes you to court, the term ‘aggressive’ used alone could be interpreted by the attorney as a positive characteristic, not a negative one.
- If a client is unemployed, there may be more to the situation. Clarify your entry by adding something like ‘has been fired from last three jobs for drinking and excessive absences’.
- You can define the term ‘nervous’ by writing something like ‘not eating; sleep is not restful; screams at children’.
- Instead of ‘feels bad’, write ‘history of high blood pressure and heart condition’. Remember: one can feel bad physically and/or emotionally. That holds true for another one-word problem: health. Enter something like ‘asthmatic condition requires expensive medication, so the client does without’.
- When the client is ambivalent, you need to know why. So does a record user. Enter something like ‘She cannot make a decision about continuing in a marriage with an abusive spouse’.
- We often think we are describing a behaviour when we say, ‘Henry is lazy’, or ‘Laura is aggressive’, or ‘Karen is withdrawn’. These statements do not describe behaviours; they make undefined judgmental observations. That could be disastrous for a supervisee and the agency. What characteristics or symptoms give you cause to think the way you do? Write them down!
As you are choosing words, remember, it is a complex task. Your choice could convey, deliberately or not, a view that tends to be too negative. Consider these examples and decide which is better: dumb or limited intelligence; cheap or economical. It is vital that your words be clear and precise to satisfy your profession, external auditors, your client and attorneys, should the need arise. It is necessary to substantiate your observations and give them authority. Remember: good entries are precise and current.
There is also the matter of timeliness. The word ‘current’ is a directive to record information immediately. Waiting even one day can blur accuracy. Those who wait until the last minute to write their entries often suffer from fainting spells, anxiety attacks and acute writer’s elbow – a heavy price to pay.
Your client should be an active participant in setting goals, writing staff notes and plans and document client participation, perhaps including the client signature. Set goals the client will understand, agree with and accept. Objectives must be specific, measurable and meaningful to the client. Set a date for achievement of those goals. Define the methodology to be used in goal achievement. Do not create a reasonable doubt – that’s a lawyer’s job! Using words that are not specific or that create vague impressions could equate to an opinion, leaving room for reasonable doubt and the possible destruction of your credibility.
The writer’s reasonableness and credibility can be assumed not only from the words but also from the readability and appearance of the record. Did you ever stop to think that a record’s appearance affects a reader just as the appearance of a speaker affects a listener? There are several major factors that will influence the written word’s credibility and clarity:
- Scrawled, scratchy or sloppy handwriting, which is difficult or impossible to read, may make the writer appear irresponsible, fairly or unfairly.
- Small writing that is crammed into a small space not only says something about the writer’s concept of what is important but also frustrates the reader, who may already be looking for a way to use the record against you.
- Disorganised filing, half-completed forms and a rambling assortment of ideas leave too much room for doubt.
Not taking care of the appearance of a document may be construed as an indication of disregard for the client and a lapse in professional accountability.
Excerpted from: ACA Legal Series: Volume 2: Documentation in Counselling Records Author: Robert W Mitchell, ACSW Series Editor: Theodore P Remley, Jr, JD, PhD
Reprinted kindly with permission for educational purposes, in gratitude to the authors and American Counselling Association.
For more information, see www.counseling.org/Publications/FrontMatter/72851-FM.pdf.
