#23. Systems Series Part 3: Write Session Notes in Minutes with These Tips
Episode Shownotes:
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 episode, 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.
In this episode, you will learn:
Why systems are crucial to getting more done in less time
The most common reasons speech pathologists and other clinicians fall behind in documentation
Five questions to answer to create your own customized system for session notes
My own streamlined system for session notes that has saved me time and helped me stay on track with paperwork
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Episode Transcript*:
This is Your Speech Path: Mindful Time Management for the Busy SLP. My name is Theresa Harp and, as a mom and speech pathologist turned productivity coach, I know a thing or two about how hectic life can be. If you're an SLP who's overworked, burnt out and feeling like you're constantly falling short as a therapist and a mom, then this is the podcast for you. I cover time management and mindset strategies so you can learn to love your work and your home life at the same time. Let's dive in.
Hello SLPs, welcome to Episode 23, where I am kicking off the third episode of the System Series that I'm doing, and this episode is all about creating a system for session notes. So if you haven't caught up, if you aren't caught up on the part one and part two episodes of this series, be sure to check those out. The first episode was about creating a system for CEUs in terms of tracking, and the second episode of this series was about creating a system for session planning, or lesson planning, however you refer to it, and that episode is a great segue into today's topic, which is again all about session notes. So, for the purposes of this episode and being consistent, I'm going to do my best with my wording, my semantics, and I know there are many different names for session notes. You might hear them called daily notes, you might hear them called treatment notes, you might hear them called SOAP notes. I'm going to call them session notes for today and I'm going to do my best to stay consistent with that. But I want to talk with you first about some of the reasons why it is so useful, helpful and important to have a system for session notes.
First and foremost, anytime there's something in your business or in your work as an SLP that you do routinely, repetitively, regularly, those are great tasks that are. Those are tasks that are ideal for creating a system, because systems can help save you time. They can also help make you work more efficiently, more focused, and I would argue that they can help to decrease some of what I call mind drama. Because, let's face it, as SLPs, I think I can speak for almost all of us when I say that we really hate writing session notes. And when I say that we hate them, I mean that when we think session notes, I think, at least for me, my immediate reaction is oh gosh, so annoying. Right, they're a necessary evil. We have to do them. They have their purpose and their merit, of course, but I mean, let's face it, it isn't the most exciting thing to do. They take time, they take thought, they take effort, and when you're already so busy as an SLP, it's another thing on your plate that you have to juggle. And so my approach and my perspective is these are all the more reasons to create a system. Okay, and I want to acknowledge that there's probably some of you who are thinking I can't create a system for this because I'm not the boss, or I can't create a system for this because I'm drowning, and creating a system is really overwhelming and that alone is time consuming and takes effort and attention and energy, and I don't have that. I'm drowning, I'm trying to keep up, I'm just trying to keep my head above water, right?
These are some of the limiting thoughts that might pop in your head when you hear me talking about a system for session notes, and I hear you. I want to acknowledge that those are thoughts and I want to let you know that I understand where you're coming from. I've been there, I get it, and I also want to encourage you to consider the possibility that these are all the more reason to have a system for session notes. This is a system can be simple, it can be quick, it can be easy and, in fact, usually the systems that I create and use are simple, quick, easy. And also it can be a slight investment of time up front. Because, let's face it, if you're going to create a system, you are going to have to pause and think about how that's going to work. What am I, how would I do this, what do I need to know? And so that will, yes, perhaps slow you down at first, but the ROI, the return on investment in terms of your time, is so valuable. It is so valuable, and the ROI, not just in terms of time, but also in terms of energy and the mind drama, also huge. So let's just, let's just move forward with the openness to hearing what I'm about to tell you, and I would offer to that simply by listening to this podcast episode, which I'm going to try to keep under 30 minutes.
Let's see, by listening to this episode, you are investing your time already and perhaps you might not need anything else besides this episode itself to get you up and running with a system. Okay, so keep that in mind. It's possible, all right?
I also want to acknowledge that there might be some of you who are listening that might be limited with what kind of platform you can use for your session notes. So, for example, I provided coaching for a private practice and their team of employees. They were required, or for whatever reason their system was to handwrite their session notes. That's what they had come up with for you know, I don't know, maybe it was because they had to, or that was what worked best for them, and so they couldn't then—at least the employees couldn't just decide to do an electronic session note, for example, right? And so you might be limited based on where you work, who you work for. If you are not the boss, you might be limited with what, how you can type these notes or, if you have to, if you can type them or if you can write them. You might also be limited with what format you have to use for your session notes. Right, if you are in a medical setting, you might need to use a specific format, like a soap note. Okay, but don't use these circumstances against yourself. Ask yourself what can I control? How can I make this quicker and easier for myself and still follow the parameters and guidelines or requirements of my current place of employment. Okay, so think about that, and if you're someone who is the boss or is free to choose how and where you're doing your session notes, then definitely listen to this episode, because I'm going to give you some really great food for thought in terms of how to create something that will work for you all, right?
Okay, so we got that out of the way, and the next thing that I want to address there's kind of three things that I'm going to do in this episode. The first one is to identify the main reasons why you are behind in session notes, or why session notes are such a pain for you. Okay, you can probably rattle off a few, but I want to spend a little bit more time digging into this, because I have some thoughts that you might not have considered. Then I'm going to give you the step-by-step framework of how to create your own system, okay, so I'm going to give you sort of questions or factors to consider that will help you to identify what system you want to use, and then I'm going to give you my system. I'm going to kind of walk you through what I created, so you have an example and you can kind of see this in action.
Okay, so let's start with the main reasons why session notes are such a bone of contention, such a pain point for you. Okay, I think there are a few common reasons why, so I want you to listen to these and ask yourself which of these describes me, okay?
Number one are you writing too much information? Maybe the reason why you really dislike your session notes is because you are writing too much, because you're being too lengthy, too wordy, too detailed in what you write. I remember when I was in grad school, I had a supervisor or professor who would look at my session notes and they would always look at your SOAP notes and give you feedback. And the common piece of feedback that I got, the most common piece of feedback that I got was that I was writing too much. And so she gave me—this supervisor who I'm thinking of—she gave me some tips on how to be more concise, right. So she was reminding me that you didn't have to write absolutely everything that happened. She suggested doing abbreviations or shorthand, things like that, anything I could do to make the process quicker and to be briefer in what I was writing. So ask yourself am I writing too much information and, if so, why? What can I do about it?
Another reason why you might be behind in session notes is because you're not scheduling time for them. So the most common approach, the two most common approaches that I like when it comes to session notes are either five minutes at the end of the session, so before the session has ended, but the last five or so minutes of the session, or five or so minutes after the session has ended, and then deciding which option is going to be your primary course of action, and you can use the other one as a backup and then have that time built into your calendar. Okay, I think it's really important to factor that in to your day, because one session note isn't going to take all that much time. But if you're seeing eight kids in a day, 10 sessions in a day, we're talking about quite a significant amount of time. If you spend, at most, five minutes and some of you might spend more if you spend five minutes on a session note and you see 10 sessions, you do set 10 sessions in a day, that's almost an hour of time that you're probably not budgeting into your schedule. And I say this with love and I say this without judgment. I recognize that many of you don't have that time, or you might feel like you don't have the luxury of scheduling that time or using the five minutes at the end of the session or building in five minutes after the session to write your notes. So think about that. Is that true? Or could you do something differently in, say, your schedule and your planning in the session itself to allow for that time and to budget it in to your day? Who do you need to talk to? Is there a supervisor or staff administration that you need to talk to in order to figure out how that can happen? And again, this is not me judging. This is not me saying that you're doing something wrong because you haven't done it this way. This is me inviting you to consider the possibility that you could do it this way and what would need to happen in order for that to become a reality.
Okay, third reason why you're behind in session notes, or why you dislike them so much, is because you don't know what to write. So for me, when I would finish a session and I would sit down and write my session note if I didn't have back-to-back sessions and I was doing it after the session had ended and I had a little bit of time, I would sit down with a blank piece of paper and I would look at it and I would feel overwhelmed. I would feel lost. I didn't have direction. I wasn't sure where to go. I was like, oh my gosh, what did we do in the session? And that's if I was writing it immediately after the session. But there were times where I wasn't writing them even that same day. Probably shouldn't admit that, but I know I'm not alone. And so at that point I certainly had forgotten, absolutely had forgotten, what went on in the session, and so it felt really overwhelming and hard to get started.
Those of you who have a diagnosis of ADD or maybe you feel like you do have ADD, you're just not diagnosed you might know that one of the common challenges with ADD/ADHD is difficulty initiating a task right, difficulty starting the task itself. So I have a tip for you. My tip is to think about your session note during the session itself. When I started doing this, it was a total game changer for me. This will be easier for those of you who have more experience as SLPs, and this will be more difficult for those of you who are newer, because as newer clinicians, you're juggling so many things in the session, you're thinking about so much that it might feel difficult, if not impossible, to think about your session note during the session itself. But I promise you, if you start to get into that habit, it will make a big difference. Once I started quote unquote writing the note in my head during the session, things were more efficient. Even if I wrote down simply one word in the session, one word in the session, and put it on my session note. Then, when the time would come to sit down and write the note itself, I had a starting point. It didn't feel impossible. It wasn't like I was starting from scratch. Just one little phrase, one little word. One little phrase gave me the momentum that I needed and the trigger that I needed to help me remember what it was that I was going to write. So that is an option that's available to you.
Okay, and then another reason why you dislike writing session notes, or why you're behind, is because you're trying to make it perfect. You think that it needs to be written. It needs to be comprehensive and detailed, it needs to cover everything. It needs to be written in the right professional tone. The data needs to be accurate. Well, the data should always be accurate, but you know what I mean. You have this pressure on yourself, that you're putting this pressure on yourself to be perfect, to write the perfect note, to make it the way that you want it to be. Probably something that's maybe more common for newer SLPs than SLPs who have been doing this a long time, but even SLPs who have been at this for a while, many of us tend to be that sort of high achiever, perfectionist personality where we might have these, whether it's spoken or unspoken, these thoughts of perfection that are holding us back, and so I want you to look at that, acknowledge that, if that's you, and ask yourself is it true? Do I have to make this perfect? Is it even possible to write this perfectly? And then I would ask you to simply consider the possibility that. Is it possible that done is better than perfect? Can done be better than perfect? And I would say yes. I would say think about who's reading this note, who is it for, and that can help you gauge what you need to write and how “perfect” it needs to be, and I would also invite you to keep in mind that the more time you're spending on a session note means the less time you have for the other things that you want and need to do in your work as an SLP. Okay, that time is costing you time spent somewhere else. So do you want to write a perfect session note or do you want to write a solid evaluation report? Do you want to write a perfect session note or do you want to have a great session plan for your next session? Do you want to write a perfect session note or do you want to go research or learn more about a new diagnosis or population that you're working with? Right, think about this as an investment of time and ask yourself how can I write a session note that I am satisfied with without it costing me time and energy that I need for the other areas of my work as an SLP, okay?
Okay, so I'm going to give you a little bit of a summary of what I'm going to be talking about today. Mindset here is key. I'm going to give you strategies in terms of creating the system, but the mindset is what needs to be addressed. You have to look at what these thoughts are. You have to get really curious about the thoughts that are circling through your brain about session notes. Be open and honest with yourself about what those thoughts are, or the micro thoughts that are keeping you stuck, okay, and address those thoughts and change them, because once you address those thoughts and change them and you start implementing the strategies that I'm going to offer you, you're going to find that writing session notes will be a totally different experience for you. Okay, alright, so those are the main reasons why you're behind in your session notes, why you dislike them so much, and that gets to some of the mindset issues that I was mentioning.
I want to also offer you some questions or some guidelines to help you in creating your own system for session notes. Now, to be clear, in case this is the very first episode you've ever listened to, when I say system, all I mean is a simple process. I don't mean an elaborate, high-tech, complicated workflow that you have to complete. That's going to add time and effort and energy. Systems are simple. They can be absolutely very, very simple, low-tech things that you do. So please don't let that word deter you from exploring the possibility of creating a system for session notes or any other aspect of your work as an SLP, and even in your work or your home life, if you are a parent or caregiver, writing a household, stuff like that. We're going to do a whole other series of episodes on systems for your home, for your personal life. So that's another series for the future. But I just wanted to make sure that you're not discounting this topic, this episode, because you think it's just way over your head and too complicated, because it's not, I assure you, and when I share my system with you, I think you'll start to understand how simple this can really be.
All right, so for those of you that are willing and able and ready to create your own system for your session notes, we're going to go through some WH questions to help guide you on how to do this and personalize it for you. All right, so step one is to identify the what. What is the format of the session note? This also includes the content that you need to document. What do you need to include in your session note, what information needs to be in there and what format does it need to be structured in, if any? Okay For me. I was a private practice owner. I got to decide—I was private pay—Igot to decide what I wanted my session notes to look like, so I had a lot of freedom and flexibility. You may or may not have that same freedom and flexibility, so you need to identify the format, i.e. the content, of your session notes. So get very, very clear first on that. What do you need to include in your session note? Okay, that's the what.
Step number two is to identify where. In other words, where, are you writing and keeping these notes? Are you handwriting them on a piece of paper and, if so, where are they being stored? Are they being stored in a paper file that you keep in a filing drawer? Does anyone still do that? I bet there are people that do. Are they being kept in your EMR, your electronic medical records platform? Are they being kept in your? Are you maybe handwriting them and then scanning them into an electronic medical records platform or into an electronic file system? So you need to identify where you are writing the note or documenting the note and then keeping it. Okay, that's going to look different for every person. If you have the freedom to do to decide this on your own, I would really look at what's going to be the simplest and easiest method for you. Right, ask yourself what are you most comfortable with what's easiest for you. Start there. You can always tweak as you go, all right.
The third step in creating your own system is to identify when. When are you going to write the note? I talked earlier about the possibility of writing it within the session. I talked earlier about the possibility of scheduling time at the after the session, after the session has ended, and writing it then? Do you have, is there any possibility that you could do either of those? Those are my two favorite approaches because they are the, I would say, the least likely to create work down the road. If it's immediate, it'll be quick, it'll be, it'll be faster than if you did it later on, after the session had ended. You know, and had had ended for some time, and you really need to figure out how you can make this happen. In other words, if you want to make it, if you want to write your session note at the end of the session but before the session has ended, how are you going to do that? Who do you need to…how do you need to budget your time within the session to be able to have five minutes at the end to write it? Who do you need to ask if you want to write it immediately after the session has ended. Do you need to ask somebody to, you know, adjust your schedule a bit? Do you need to change the way that you're spending your time in terms of planning for your next session or prepping for your next session? So you need to identify the when.
Okay, so we've got Step One was the What. Step Two was the Where. Step Three was the When. Step Four is the How. And when I say how, I'm really talking about how long. How long will you budget to write each note? You need to decide this ahead of time. It is possible to decide this ahead of time and to stick to it, and that's what I want you to do. I love the idea of setting a timer and using that timer to get your note done within the amount of time that you have determined you will use to write the note. So, if you want to write a note in five minutes, set your timer for five minutes and get going. And also, I will add, I like timers that are analog ones that you can actually see the time going down. I use a time timer and I love it. I used to use digital timers, but I couldn't actually see the time, and so it would be, you know, lost. I would get lost in the time and I wouldn't realize if I was one minute in or four minutes in, or seven minutes in until the timer had gone off. Right, so that's what you need to determine is how long are you going to budget to write the note? And then I would also challenge you can you get it done even faster, right? Maybe right now you want to start at 10 minutes if you're newer to this…how do you get down to seven? If you're at seven? How do you get down to five? If you're at five, how do you get down to three? Okay, so think about that.
And then, last but not least, the last step in creating your own system for session notes is to identify the Why. And when I say why, going, what I mean by that is “why are session notes important?” What do I mean by that? Well, what I mean is who's going to be reading this? Who is this for? What is the purpose of this session note? Is it for insurance? Is it for the school system? Is it for your own data collection? What is the purpose, why? What is your why? Why are you writing this note? What are the reasons that you're writing this note? Because that will help you to answer the earlier questions that I asked—Steps One through Four, the what, the where, the when, the how. Right, if you're stuck with coming up with answers to those questions, identifying the why, why session notes are important, will help you. And then the flip side to that is why aren't they important? That can help you get really clear on what you don't need to include in a note that maybe you've been wasting time on writing up. Why aren't session notes important? Well, if they're not important for documenting, I don't know, which family member brought the child to the session then that's not something you have to document. Don't waste your time on that. This is a very personal question. This is a question that you need to answer for yourself and your place of employment or your setting, all of that. So why are they important and why aren't they important?
All right, so those were the five steps to create your own system. The last thing I want to take you through before we wrap up is my system, just purely as an example, to kind of give you some ideas, to give you a visualization, not to tell you that this is the one right way and the only right way. Okay, so I'm going to share what I did, but I want you to take this with a grain of salt. Take it if it helps. You leave it if it doesn't. Okay. So I might have mentioned this earlier, but essentially what I did was I combined the format of my session plan, or my lesson plan, with my session note itself and basically made sure that all of the components that I needed and wanted in a session note had a space on my lesson plan. This was such a game changer for me. It reduced the amount of paperwork or the number of forms. It reduced, essentially, having to toggle back and forth from one document or file to another and I could basically see everything in one place. Because to me, the session note and the lesson plan really do go hand in hand. What I do is I create my lesson plan in advance and then, when I'm starting the session, I pull up that lesson plan so I have it on my iPad. I used to do this on. I've done it multiple ways. I used to do it on a printed piece of paper that I hand wrote and that, as you can imagine, was time consuming, but that's just sort of how my brain operates, so it worked really well at the time. Then I had it on a Word doc and at the end of a session I would open up my computer and I would start typing the session note. I really liked that because it was quick. I was typing up the notes right there while the family was still in the session it was like the last five minutes or so and while I would have the family, play with my client, with the child, and practice some of the strategies that we were working on, I would type up the session note. But now what I do is I have it on my iPad as a working document that I can write on directly using the GoodNotes app with my Apple Pencil, and so what I will do is within the session itself I'll start writing. So, for example, I will take data on the session note and I'll have it right there so that at the end of the session I can just calculate the data or compute the percentages or whatever it is, and then I have the O in the SOAP note. I have that information. The objective information, the objective data is right there. Keeping it electronic also helped me to limit the paperwork, limit the number of pieces of paper laying around. And then what I would do was I would email a copy to the family immediately at the end of the session, so before they leave I would send them an electronic copy. Okay, so just to sort of summarize what that system, what my system is, in case this helps you, is I have a template for my notes and that template includes the session plan and it includes space to write the session note and I have that open on my iPad within the session. And so while I'm in the session I'm taking whatever notes I can. If I'm with a kiddo who is distracted or, you know, it's very hands on, very quick I might not be able to write on the document, write on the session plan and the session note right away. I might have to do that towards the end, but that's okay. And then I'm just writing as I go, or I am making mental notes and filling it in at the end of the session, depending upon what that client looks like and what the way that that session is going. And then I email a copy to the family, so I have an electronic copy on my files and then they have an electronic copy via email.
Couple of caveats or sort of disclaimers here. Number one you need to make sure that whatever system you're using is HIPAA compliant. So if you are emailing something to the family, it of course needs to be protected and within the guidelines and requirements of HIPAA. And the other thing is I like to ask the families whether they prefer an electronic copy or a hard copy. I know for some people, if it's electronic, it's out of sight, out of mind, and then they will never even look at that document because it's just for whatever reason, right? Whether it's they have a neurodivergent brain or they're just incredibly busy or whatever. Whatever the reason or reasons may be, if they're not going to look at something that's sent to them via email, I'm printing a copy and handing it to them within the session. Okay, so that's something to keep in mind. Do you have a family that is more paper friendly, likes paper, or do you have a family that is more electronic friendly? Right, I know for me, if someone hands me a piece of paper, I'm most likely going to find it on the bottom of my like a pile of papers and stuff in my car, like weeks later. That's probably how it's going to go. Nothing against anybody. That's just the way my life. That's the way things go in my life these days. Other people you give them a piece of paper and it is put in a very special, safe spot and they know exactly where it is, and so on and so forth. So you really need to work within the learning styles and personality and lifestyles of the clients that you are working with. Now, of course, if you have a very big private practice with lots of therapists working for you or lots of families or clients that you're serving, you may not want to modify the way that you work your system in order to serve families. You might need to make a one size fits all decision here, and that's okay. You really need to get clear on what is your individual practice look like if you are a private practice owner, and what are you able to do in terms of flexibility. What do you want to do? And you then get to decide how you want to structure this system. Whether it's some version of my system or some creation of your own system that works for you and the clients that you serve. You get to decide.
Alright, that is pretty much everything I've got for you in terms of creating a system for session notes. I hope that this was helpful, but would you do me a favor, if you're listening to this episode, would you take a minute? Two things take a minute number one and just click the follow or subscribe button on the podcast. That way you don't miss any future episodes and it helps other people who haven't yet discovered this show to find it. So if you could do that, that would be fabulous. And if you're willing to give just a little bit of your time to leave a review, it can be as simple as clicking the number of stars, or you could go ahead and add in a comment or some feedback. I love reading the reviews. It means so much to me and, again, it's just another way for other people to find the show. And, as always, don't forget to join the free Facebook group “SLP Support Group.” I'll link to it in the show notes so that you can come in, join the group, continue the conversation and get access to additional workshops, trainings, resources, all sorts of fun stuff like that.
Alright and I will be back next week for another episode, part four of this systems series, where I'm going to be talking about a system for evaluation reports. Dun, dun, dun. So make sure you check that out next week. When it comes out. Alright, I'll talk to you all then.
*Please note that this transcript was generated by AI and may contain errors.