#23. Systems Series Part 3: Write Session Notes in Minutes With These Tips
Session notes-we know they're necessary, but as busy clinicians they can feel like one more thing on a never-ending To Do List.
What if I told you that it's possible to write a session note with very little time and energy? In today's blog post, I'm walking you through a simple, effective system for taking session notes that will not only save you time but also reduce the stress that we often experience when it comes to documentation.
Let's start by addressing the importance of establishing a system for your session notes. For most speech-language pathologists (myself included), writing session notes isn't the highlight of our day. It's time-consuming and can add to the overwhelming workload we already have. However, when tasks are routine and recurring, that's precisely when systems can come to the rescue. Systems save time, streamline work, and significantly reduce the mental stress we often associate with such tasks.
Now, before delving into the nitty-gritty, let's acknowledge some common hesitations. You might be thinking that creating a system for session notes will be overwhelming or time-consuming, and if you’re like most SLPs, you have very little time to spare. However, creating a system for session notes doesn't have to take you a lot of time. In fact, the systems I use in my own practice are simple, quick, and efficient. While setting up a system might require a bit of time up front, the benefits—both in time saved and reduced stress—are invaluable.
Identifying Common Challenges
Let's start by pinpointing why session notes might feel like such a challenge or a burden:
1. Information Overload:
Are you being too detailed in your session notes? If so, that might cause underlying feelings of tension or avoidance when it comes to writing your notes. Consider what information is absolutely necessary and eliminate anything else.
2. Time Management:
Finding dedicated time for session notes is crucial. Allocating five minutes at the end of each session or immediately after can significantly ease the burden.
3. Content Creation:
Do you feel lost when staring at a blank session note, wondering what to write? Consider drafting your session note during the session itself. Just a word or phrase can serve as a starting point when you sit down to write the note later.
4. Pursuit of Perfection:
Do you feel a sense of pressure to craft the “perfect” session note? If so, it is costing you time and energy. The more time you spend writing a session note, the less time you have for your other work-related tasks. Done is better than perfect.
Developing Your Session Note System
Now, let's explore how to craft your own streamlined system:
1. Determine the "What"
Identify the necessary content for your session notes. What specific information must you include? This could vary based on your setting or employer's requirements.
2. Define the "Where"
Decide on the platform or format for your notes. Whether it's handwritten with paper and pen, stored electronically, or a combination, choose what's most convenient for you.
3. Establish the "When"
Set aside time in your schedule to write session notes. Whether it's during the session or immediately after, making it a routine part of your workflow is crucial.
4. Nail Down the "How Long"
Budget a specific time limit for each note. Start with a timeframe and challenge yourself to gradually reduce it without compromising quality.
5. Uncover the "Why"
Understand the purpose of your session notes. Who will be reading them and what information will they expect to see? Considering these factors will guide you in determining what to include and what's unnecessary.
Sample Session Note System
Let me share my system as an example, though remember, this is NOT a one-size-fits-all approach:
I combined my session plan with the session note itself, simplifying the process. In doing so, I could see the plan for the session as well as the space for data collection and analysis, all in the same place. I use an iPad with an Apple Pencil, which allows me to handwrite my data and notes without loose papers laying around, cluttering up my desk. At the end of each session, I finalize the session note, email a copy to the family, and keep an electronic copy for myself. Before the next session, I duplicate that form and edit the content to reflect the upcoming session date, plan, and space for new data collection.
Remember—done is better than perfect!