High Risk and Sensitive Phrases for Progress Notes

Although mental health therapists should never try to hide critical information from therapy notes, there are many times when writing the details is unnecessary or even undesirable. So what do you write instead?
In this livestream Dr. Maelisa McCaffrey will give mental health counselors specific phrases to use for case notes when sensitive and high risk topics are addressed in a therapy session. She will also address how much detail you need to document in these scenarios and provide guidance on how to make these decisions ongoing.
Specific topics to be addressed include:
Documenting a history of sexual or other abuse
Discussing things like ongoing court cases with clients
Exploring gender identity with adolescent clients
Navigating diagnosis requirements by insurance with sensitive information clients want to remain private
Join us at 12pm Pacific Time on Wednesday, July 19th to hear all the great suggestions!

[@barbgris]

This was a really great video. I'm glad you said clearly that we shouldn't hide things from our notes that are relevant. When I was on the California Ethics committee I saw people not protect themselves by writing notes that were too vague ("discussed relationship issue"). It was a great idea to really inform clients upfront about session notes -- I just added to my treatment agreement "I am legally and ethically required to keep notes about what is said in session, what actions I take, and what advice is given to you in each session. If you have concerns about these notes, please feel free to ask."

[@SteffiP4Liberty]

I have not been able to find anyone else talking about this subject. Thank you for covering it!

[@allahnakaj]

Your video was very helpful for developing my perspective as a new supervisor. Thanks!

[@lindsaymerrill2569]

Thank you so much for this video and your time and knowledge- so so very helpful as a new therapist!!

[@annejasonmrazlive8368]

Very helpful, thank you.

[@notedesigner1722]

Excellent!

[@patriciamorgan2501]

Yes !!

[@trishannelininger1206]

Maelisa I listen to you alot...and of course as a licensed therapist I need 36 BBS hours. Have you ever thought about making these You Tubes with a test at the end and providing 1 hour BBS qualifying training? I also work with your paperwork in particular your examples of treatement plans and progress notes: I like the one that has topic/intervention/client participation and plan,, which obviously isn't soap, dirt or dap, but as I work in private practice alone, cash, no insurance it works out well...I am working on getting them from hard copies into click boxes, but its a struggle for my lack of knowledge. Have you ever thought of making your paperwork electronic?

[@MaelisaMcCaffrey]

As of right now, it’s just electronic document templates that people can use if their EHR allows them to create their own template. You could also use them within Google Workspace. But it would be far too much effort to create an electronic system for my templates without it being an EHR itself… it would end up being an additional tool (with added cost) and an additional step. Now if the EHR wanted to make my templates available within their system, that would be ideal! Will see if we can make that feasible in 2025 😉

[@trishanne78]

Ooh wow...that would be wondeful...I use Simple Practice 😊

[@MaelisaMcCaffrey]

@@trishanne78 let them know you want my templates 😉

[@videt7459]

What about vagueness when it comes the dystopian nightmare that is now reality: Supporting a client in processing thoughts & feelings about wanting an abortion in a state where they are illegal?

[@MaelisaMcCaffrey]

This is a really difficult one and I feel like there is no one “right” answer. I would probably discuss processing emotions around pregnancy. That is an extremely relevant issue. And if the pregnancy ends at some point, I would simply use that language. Pregnancies end for all kinds of reasons all the time and people have deep feelings about it regardless of the circumstances. Lastly, always use your clinical judgment above all. Consult with your local or state ethics committee if available. This will continue to be a difficult issue for therapists.