Using Template Case Notes the Pro's and Con's to
Jun 30, 2019
Let us get straight into this. We'll start with the con's.
1. You will need to be using a client management system.
Some practitioners are still using pen and paper. This is great (in fact, this blog was drafted on pen and paper); however, with more and more technology coming about, your practice is at a huge disadvantage of staying old school. (think the cost of supplies cost of long term storage, risk of confidentiality breaches.)
2. Sometimes a client doesn't fit the "mould."
Yes! You want to be able to show individuality and specific detail in your notes. However, sometimes it can be draining and we lose sight of the important details (we mean you might add too much detail). Think of it like this, if Mark Zuckerberg (who?) stopped wearing different clothes to work, then maybe there is something to be said for streamlining your notes.
3. It doesn't look very professional.
Obviously, even with template notes, you will need to edit the details of the note. You can either set up a template for each client and copy and paste from one note to the next or you can set up a template and copy and paste from client to client. The issue with this is that clinicians forget to update all of the details related to the specific client or they will cut and paste from the wrong client. Being detail oriented is vital! If notes are subpoenaed and they have the wrong client information in them, its a severe breach in the client's privacy.
You don't have to think. You know exactly what you need to document. What to take away from each session. You can even add a section at the end, "remember for next time" if you want details for yourself.
2. Helps you stay compliant.
It allows you to ensure you are meeting your Medicare requirements. It also provides you with the ability to cover any extra areas of compliance that other payer sources may ask of you. If you apply all requests to all clients, you will always be 100% compliant for every payer source.
3. Allows you to reduce the "clutter" of your session
If you're just starting out in private practice, having a template allows you to understand what are the important "take away's from the session.
Most templates ask for your future planning ideas for the client. This allows for you to put some structure into the client sessions. Working smarter, not harder.
Overall, it's important for you to find what feels good for you and your own needs in practice.