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What Did You Say? 5 ways to document said In Your Progress Notes

2/23/2022

1 Comment

 
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​Do your notes ever feel a bit stale? Like a CD on skip.  Ack - are CD's even a thing anymore? 
 
When I write my notes I use a DAP note formula - Data (subjective and objective - or more simply what the client said and what they did in the session), Assessment (making sense of the data section), and Plan (what they are supposed to do in between sessions and what is on the agenda for next session).  
 
With this format in the Data section we are capturing what the client and/or parents said or did.  AND when I am writing up a Diagnostic Assessment I am using quotes or being really clear on where the information came from - the client, parents, guardians, or past records.
 
What this all means is I am typing in a lot of information all day long about the things that are coming out of children and parent’s mouths.  And let me tell you - a note that sounds like “Peter said ___________. Peter also said _________. Peter’s mother said ___________.” gets pretty darn redundant and borning.
 
So…. on that note - today I bring you 5 ways to document what a client said (without saying said) so you can shake your notes up!

  • Client reported ….
  • Client stated….
  • Client noted…
  • Client observed…
  • Client commented…
 
Wheeeeww!  That was short and sweet, but some of my favorite ways to add variety to my progress notes! 
 
Want more notes support? Check out my free mini webinar for faster progress notes and Play Therapy Progress Note tips.  

Still need more support? Learn to shrink your note writing process to write effortless and effective notes within your therapy day!  Check out The 5 Minute Note Course! 
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1 Comment
Bigbrinjal - online medicine store link
10/17/2023 05:10:36 am

Good post!

Reply



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    Hi, there!

    I'm Ann Meehan, an LPCC,
    ​RPT-S
    ™, and EMDR Consultant. I help therapists that work with kids and teens go from a place of stress and survival to inspired and thriving.  I give child therapists the resources, tools, and skills they need to be effective and confident in their practice!

    I am organization obsessed, coffee loving, playful therapist who is showing up for life in the north woods of Minnesota. 

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  • Home
  • Blog
    • The Playful Therapist Blog
  • Courses
    • Online Courses and Training
    • Speaking
    • Local Trainings
  • Supervision
    • Supervision | Consultation
  • Resources
    • Downloads
    • About Play Therapy
    • Continued Growth and Learning
    • Recommended Readings
    • Online Sources for CE
    • Professional Groups