As a mental health professional, effective note-taking is an important part of the job. Tracking the progress of your patients throughout their sessions is vital, and how you take those notes requires attention. These notes must be easy to read, well organized, easy to locate, and most importantly, safe, secure, and HIPAA compliant.
Note-taking is simply a necessary part of being a mental health professional. That said, note-taking has evolved a great deal from the classic image of the therapist doing shorthand in their leather-bound notebook. Today, you have many different note-taking methods available to you, some more effective than others. It all depends on your note-taking style and the comfort of your patients.
How Does Note-Taking Affect Your Clients?
Whether you take notes during a session or you make your notes at the end of the session is entirely up to you. Taking notes can help you keep specific facts straight and prevent forgetting important information that comes up in a session. However, it might not be for everyone, and that goes for patients as well.
Some patients may feel distracted when their therapist or mental health professional is taking notes. They might be wondering what you’re writing down, unconsciously putting up guards because of that paranoia.
If you do take notes during the session, it’s important to ensure it doesn’t distract from your real job: listening to your patients. Try to keep your eyes on them, only glancing down at your notes when necessary. If you’re ever concerned about this, you can always ask your patient how they feel about notes taken in their sessions. Often, addressing the note-taking elephant in the room can help relieve any unspoken tension they may be feeling.
Luckily, a study conducted by Software Advice found the majority of patients don’t mind when their therapist takes notes on their desktop, laptop computer, or tablet during a session. In fact, more than 80% of respondents are not bothered by note-taking during a session.
What’s Your Note-Taking Style?
Pen & Paper
Some people prefer the classic physical notepad and pen method. While this is minimally invasive in a session with a patient and doesn’t make very much noise, it’s also one of the least effective note-taking methods. After all, keeping filing cabinets full of paper notes is cumbersome and also potentially unsafe. If you plan to transfer paper notes into a digital form for safekeeping, the process can often be very time-consuming, requiring plenty of scanning or transcribing.
What’s more, the study by Software Advice found that almost half of the patients they surveyed had no preference between mental health professionals using pen and paper during a session or electronic health records (EHRs). However, when they filtered it down to only patients with a preference EHRs were the preferred method. So, for those who use paper during a session and then add notes to their EHR afterward, they are acting against patient preference.
Laptop or Tablet
Many mental health professionals use digital methods of keeping notes. This could take the form of typing notes on a laptop or tablet during a session. While this can be one of the most accurate ways to take notes, especially if you’re a fast typer, it can also be irritating to some patients who may feel that you aren’t listening to them. Add in the sound of the keyboard and this might not be the best method for an in-depth therapy session.
As an alternative to laptops, some people write digital notes on their tablets or even their phones. This would seem to be the best of both worlds, as you can quickly input information silently and accurately without looking down too often. But, again, some patients can get irritated that you’re on your phone rather than talking with them.
Stylus or Digital Pen
With advancing technology, one of the best ways to take notes might be the use of a stylus or another form of digital input like an Apple Pencil. Studies have shown comprehension and retention of information is improved when notes are taken by hand rather than typed out.
This combines all of the advantages of taking handwritten notes in a notebook while being able to organize your data in digital storage. Plus, since preference for EHRs dominates over preference for paper charting during exams, therapists who choose this method are acting in the interest of the majority of their patients.
The Most Effective Note-Taking System
Taking notes is important, and keeping those notes organized and secure is even more so. If your notes are spread over several different locations, from handwritten notes in a physical book to digital notes typed on a computer, it can be challenging to keep them all organized and straight. Thankfully, Owl Practice has a digital note-keeping system that’s specifically designed to make sure all of your session notes are precisely where you expect them to be and fully HIPAA compliant.
With Owl Practice you can store both typed notes and digital handwritten session notes Every note you take using your stylus and tablet will be saved under your patient’s profile. If you ever need to refer to them, they are easily accessible based on their file by session date. Best of all, these notes can be accessed anywhere, on any of your devices! If you’ve ever thought about upgrading your note-taking game, then this is a feature you’ll want to explore.
Also, you can rest assured that the majority of your patients will be happy with your new and improved note-taking system. This is just one of the many new features that we’ve introduced to Owl Practice over the last year, including secure messaging and practice document organization. If you’re curious about the other services that we offer, make sure to register for a free demo!
Or, if you have any questions or comments about our services, we invite you to contact us at support@owlpractice.com
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