What method do you use to take notes in sessions?
As a mental health professional, keeping accurate and comprehensive notes is a vital part of the job. You need to make sure you’re tracking the progress of your patients throughout their sessions and how you take those notes needs attention. You need notes that you’ll be able to read and make sense of later, that you can organize and easily find whenever you need them, and which are safe, secure, and PHIPA compliant.
Effective note taking is simply a necessary part of being a mental health professional. That said, note taking has evolved a great deal from the classic image of the therapist doing shorthand in their leather-bound notebook. Today, you have many different note-taking methods available to you, some more effective than others. It all depends on your note-taking style and the comfort of your patients.
How Does Note-Taking Affect Your Clients?
Whether or not you take notes during a session or you make your notes at the end of the session is entirely up to you. Taking notes can help you keep specific facts straight and keep you from forgetting important information that comes up in a session, but it might not be for everyone. And that goes for patients as well.
Some patients may feel distracted when their therapist or mental health professional is taking notes. They might be wondering what you’re writing down, unconsciously putting up guards because of that paranoia.
If you do take notes during the session, it’s important that it never distracts from your real job: listening to your patients. Try to keep your eyes on them, only glancing down at your notes when necessary. If you’re ever concerned about this, you can always ask your patient how they feel about notes taken in their sessions. Often, addressing the note-taking elephant in the room can help relieve any unspoken tension they may be feeling.
Luckily, a study conducted by Software Advice found that the majority of patients did not mind when their therapist took notes on a desktop computer, a laptop computer, or on a tablet during a session. In fact,more than 80% of respondents said that they would not be bothered by note-taking during a session.
What’s Your Note-Taking Style?
Pen & Paper
Some people prefer the old physical notepad and pen method. While this is minimally invasive in a session with a patient and doesn’t make very much noise, it’s also one of the least convenient. After all, keeping filing cabinets full of paper notes is inconvenient and also potentially unsafe. If you plan to transfer those paper notes into digital form for safekeeping, that can require scanning or transcribing, which aren’t a great use of your time.
What’s more, the study by Software Advice found that almost half of the patients they surveyed had no preference between mental health professionals using EHRs or using pen and paper during a session. However, when they filtered it down to only patients with a preference, electronic health records (EHRs) were the prefered method. So, for those who use paper during a session and then add notes to their EHR afterward, they are actually acting against patient preference.
Laptop or Tablet
Many mental health professionals use digital methods of keeping notes. This could take the form of typing notes on a laptop or tablet during a session. While this can be one of the most accurate ways to take notes, especially if you’re a fast typer, it can also be irritating to some patients who may feel that you aren’t listening to them. Add to that the sound of the keyboard and this might not be the best method for an in-depth therapy session.
As an alternative to laptops, some people write digital notes on their tablets or even their phones. This would seem to be the best of both worlds, as you can quickly input information silently and accurately without looking down too often. But, again, some patients can get irritated that you’re “on your phone” rather than talking with them.
Stylus or Digital Pen
With advancing technology, one of the best ways to take notes might be the use of a stylus or another form of digital input like an Apple Pencil. Studies have shown comprehension and retention of information is improved when notes are taken by hand rather than typed out. This would seem to combine all of the advantages of taking handwritten notes in a notebook while being able to organize your data in digital storage. And that’s becoming even more convenient now with Owl Practice!
Plus, since preference for EHRs dominates over preference for paper charting during exams you’d be acting in the interest of the majority of your patients.
The Ultimate Note-Keeping System
Keeping notes is important. Keeping notes organized and secure is even more so. If your notes are spread out over several different places, from handwritten notes in a physical book to digital notes typed on a computer, it can be challenging to keep them all organized and straight. A few years ago, Owl Practice introduced a digital note keeping system that was designed to make sure that every one of your session notes would be precisely where you expect them to be and fully PHIPA compliant. The only problem was that it was digitally-typed notes only. Well, not anymore!
Owl Practice is absolutely delighted to introduce digital handwritten session notes into our services. Every note you take using your stylus and tablet will be saved under your patient’s profile. If you ever need to refer to them, you can quickly bring them up, clearly filed by session date. Best of all, these notes can be accessed anywhere, on any of your devices! If you’ve ever thought about upgrading your note-taking game, then this is a feature that you’ll definitely want to explore in the near future.
And you can rest-assured that most of your patients will be happy with your new and improved note-taking system. Patients who took part in the Software Advice study indicated that long wait times at the doctor’s office, unfriendly staff, and short visits made them most dissatisfied—not note-taking. Only 5% of respondents felt that note-taking during a session would be dissatisfying.
This is just one of the many new features that we’ve introduced to Owl Practice over the last year, including secure messaging and practice document organization. If you’re curious about the other services that we offer, please sign up for a free demo! If you have any questions or comments about our services, we invite you to contact us at support@owlpractice.ca.
