2 Tips that Save Therapists the Most Time on Paperwork

[@Jodi_EmpowerHerTransformation]

Bullet- points! What a great solution- thank you! I would love an example of a SOAP note in bullet points please

[@chewie1355]

Thank you. I’m watching while trying got complete my documentation. Needed help

[@CarisaSanchez]

The bullet points might just be life changing

[@MaelisaMcCaffrey]

I hope so!!!

[@debbied1554]

So helpful

[@Yogi-Bajogie]

The intake form you're referring to is the same form that is in your packet right Maelisa? That is the one I have been using and really find it helpful:)

[@MaelisaMcCaffrey]

Yup, that’s the one! The big Biopsychosocial assessment with all the historical data 😊

[@lbg87]

Hi, thank you so much for sharing your insights about how to make the intake process smoother and less time-consuming. I am wondering if you also complete your own biopsychosocial/initial assessment document in addition to the intake progress note? (even though your intake assessment paperwork for the client to complete is comprehensive). *I am also located in California which I saw somewhere you were too if that helps. I've always worked under agencies up until recently and they all asked us to complete complete biopsychosocials, even if a client had completed a relatively comprehensive intake form.

[@MaelisaMcCaffrey]

Your intake progress note will simply be a progress note for the session that ocurred. So part of that note would be "Completed biopsychosocial history" but you don't need to repeat any other info :)

[@lbg87]

@@MaelisaMcCaffrey Thanks so much for responding. So just to reiterate to make sure I understand: If the client completed a comprehensive biopsychosocial before our first session, I just need to complete the intake progress note and within that, I should include: "completed biopsychosocial." Also, may I ask to confirm if it's acceptable to fill in the gaps of additional info that the client shares within the progress note if I can't go and add onto what the client already wrote in their intake paperwork? I saw that in another video, you recommended stating something like, "see intake paperwork." Would such a statement be included in the intake progress note or on my own biopsychosocial document (that I also complete, even if the client completed one themselves)?

[@MaelisaMcCaffrey]

@@lbg87 good follow up questions! Yes, just fill in any gaps in a section of your intake progress note. You can label it something like “Additional info on family history” and then include the info. I prefer that to the clinician also having a biopsychosocial they’re completing (on top of the one the client did!).

[@lbg87]

@@MaelisaMcCaffrey thank you so much for responding again! Your videos/insights are extremely helpful and appreciated!

[@CurtisTindall]

I also wish I could see an example. Are you saying that I could do this for ie, client and pt explored following topics: elder mother care-taking stress, separation from partner and adult son. This is the objective section and the subjective is that pt stressing and in constant state of fear of welfare of partner and elder son. Subjective part ?????

[@MaelisaMcCaffrey]

Honestly, this is why I hate and never used SOAP notes! But here's a suggestion of what you could do: S - Topics discussed (what client brought up/said) O - Interventions (what the therapist did) , Client presentation (MSE type presentation) A - Client progress and continued impairments/needs P - Plan until next session

[@Jodi_EmpowerHerTransformation]

Question: One thing I do not have on my intake form is where the clients work and what their profession is. I rarely find this information helpful. Please can you provide input on why/if this is a necessary question, thank you

[@MaelisaMcCaffrey]

My experience is that work life and subjects related to work do come up over time. It's a significant part of most people's life and is important to ask about, even if you don't end up focusing on it in that individual's treatment.

[@supertiger72]

in my SUD counseling, it helps with understanding if the job can be a risk to their recovery @@MaelisaMcCaffrey

[@patriciamorgan2501]

❤