Episode 21: Case Note Documentation Considerations for Clinical Supervisors with Beth Rontal

Kayla: Welcome back to your Clinical Supervisor’s Couch podcast, and I’m your host, Kayla Das.

In today’s episode, Beth Rontal, Licensed Clinical Social Worker, case note documentation specialist and owner of the Documentation Wizard, will share case note documentation considerations for clinical supervisors.

Hi Beth, welcome to the show. I’m so glad to have you here today.

Beth: Thank you, Kayla. I’m really glad to be back. I know I’ve interviewed with you on another podcast and I always enjoy it.

Kayla: Absolutely. Yeah. So, Beth has been on the Designer Practice Podcast twice before. You might have been, actually, you weren’t my first guest podcast, but I think you might have been either on my second or third when I first started the podcast. So yeah, we go way back. So, I’m so appreciative for you to be on Your Clinical Supervisor’s Couch.

Beth, before we dive into today’s episode, please introduce yourself and tell us a little bit about your practice and what you do.

Beth: Well, I have a private practice. I’m still a practicing therapist, and I am the founder and trainer for Documentation Wizard. And as the documentation wizard, I teach therapists how to translate their skill and their intuition into effective documentation that protects client confidentiality, protects therapists in board complaints, and for Americans who take insurance, it helps us to pass audits.

I actually worked in a clinic for 11 years, well for 15 years 11 of those supervising over 50 therapists, and that’s when I honed my skills as a supervisor. And becoming a therapist and a supervisor was actually a second career for me. I was 45 years old when I graduated and 50 when I became a supervisor. And I felt like I had a lot of life experience that informed how I work and how I want to pass on my sense, my belief, in people’s ability to heal to my supervisees. And since I had to also teach clinical documentation and review all their treatment plans and their progress notes, I was really committed to that process being clinically useful.

So, I guess, I was successful because the system that we used and I helped to create and I taught reduced documentation errors and that meant that the clinic was able to bill, was able to pass audits, and it saved them from going out of business. And it also meant that I spent thousands of hours reviewing case notes and treatment plans, but it helped me to understand what my supervisees were doing or not doing in session. I found it really helpful, even though you often had to chain me to the couch to do it.

Kayla: Amazing. As therapists we’re so used to case notes. However, we’re not always as familiar, when it comes to one writing case notes as a clinical supervisor, as well as potentially reviewing other people’s case notes. Because we often have our own little structure and our own little way that we create our case notes. So why is it important for clinical supervisors to review their supervisees case notes?

Beth: I think that’s a really good question and it doesn’t get asked enough because the answer is not a superficial one. And I think that most supervisors and most therapists feel that it’s superficial.

My belief is that good quality documentation is a contribution to clinical practice. It helps us think about what we’re doing, why we’re doing it, what worked, what didn’t work, why it did or didn’t work. What we might want to do in the next session. How to plan. And that can show up in your notes.

You know, I have a monthly consultation group on documentation, and I am always very pleased that the documentation questions I get turn into a conversation about the client, about the clinical work. And I think that reviewing documentation isn’t just about making sure they dot all their i’s and cross all their T’s. Not just meeting the requirements, but thinking through carefully what their case conceptualization is. How they showed up with the client. How they responded to the client. It shows up in the documentation.

When I would read in a note that the client was resistant to therapy, that was always a red flag for me that the therapist was struggling with the client and blaming the client. Rather than looking at how quote unquote resistance was a protective factor, what they were protecting, what they needed to approach with compassion. And these would be triggers for the therapist. And all of us have them. So, reading their notes would help me understand that. It would help me say, oh, she’s having a problem with this one. Let’s talk about it.

Kayla: That’s so insightful because even, before you mentioned that, I was thinking, of course we would review people’s case notes because that way we can help them improve their case notes. But what you highlight is really that implicit information. It’s the language, the discourse that we’re using in our case notes is likely reflecting the therapist’s position when working with that client.

Beth: Yes. Exactly. What they think, how they feel. I am always a bit distressed when I read personal opinion in notes. Personal opinion belongs in supervision. Not in the note. So, when I read a personal opinion in the note, we talk about it, it gets removed, and we deconstruct where that opinion comes from. Then the therapist is better able to work with the client.

Kayla: That makes complete sense. So that’s reviewing the supervisees notes. How about clinical supervisors? Should they be keeping their own notes based on the clinical supervision?

Beth: Oh yeah. First of all, therapists come in and talk about the same client over and over again. So, if the clinical supervisor has notes, then they can look at the note, read it, refresh their memory, just like a session. Supervision is like doing a session with a therapist, right? It’s not to do the deep therapy work, but it’s to do enough work so that the therapist can work with the client. So, keeping a record is really important.

And there are times when there are consistent issues that come up for a therapist, and the supervisor needs to have a record of it. It could be that there’s a record of inappropriate behavior, and you have to have a record of that because you can’t just spring it on somebody out of the blue. It has to be documented.

In terms of the documentation piece of it, you want to keep track of how the therapist is doing, meeting all the requirements. Because if they’re not meeting all the requirements, that has a direct impact on either the clinic or agency you’re working for, or the private practice therapist.

And it’s our job to help the therapist protect themselves and help the clinic protect themselves.

Kayla: When it comes to clinical supervision notes, what do you look for in that note? In other words, is there a specific format that it should be written in?

Beth: A format for a note is what I teach in my workshop. I can kind of run through requirements, but it’s too much to teach the format because of how I conceptualize it, put it together and help people really understand all the different kinds of assessments. Because in most Notes they have a big box that says assessment. And therapists are always assessing from the moment they start working with the client. So, what actually goes in there? So, I break all of that down.

What I look for when I’m reviewing a note is that they meet all the administrative requirements, the ethical requirements, and the clinical ones. I ask them how long does it take you to write your notes? And if they say, it takes me 20, 30 minutes, I’m like, oh, this is unsustainable. How come? And it often reveals a lack of training, not knowing what or how much to write. Because frankly, most of us were not trained. We were either told, be vague, or if it’s not written, it didn’t happen. Well, how do you marry those two?

And it’s important for supervisors to understand when it’s important to put details in and when it’s important to not tell the story. So, I look for that. And I want to make sure that they’re not writing too much confidential information. Because, let’s face it, mental health is still stigmatized.

And just in case our notes get subpoenaed and we can’t protect them from going to court, which happens, we want to make sure that we’re clear, we’re representing ourselves, and the client accurately and carefully. So, I look for that. I look for blaming language. I look for a therapist feeling frustrated. That’s the kind of thing I look for. I mean, the requirements, at least in the US, that they document the exact start and stop time.

Some EHRs don’t do that, so you have to do that manually. I use paper notes, so I just type it in, really simple. I make sure that there’s a diagnosis because the diagnosis is what sets up the golden thread of documentation. Everything has to tie back to it. I make sure that the bio-psychosocial stressors are documented. Because in the US we can’t bill for the stressors, but they’re often what our clients come in talking to us about. So, if we document those, we add weight to why the client needs therapy, not just because they have a diagnosis, but because there are these intense issues that they’re dealing with. So, I look for a marriage of the clinical and the administrative.

Kayla: I know you’re referring to the clinical notes of the therapist. With respect to clinical supervision notes, would the clinical supervisor document those same kind of clinical goals or outcomes? Or are They focusing on the client of the therapist or are they focusing on the therapist themselves and their progress?

Beth: I would say both. That’s what I do. I mean, the focus is on the therapist, but when the therapist comes in and says, I tried that this week and it worked, I document that client’s progress. But I’m also documenting the therapist’s progress.

As a clinical supervisor, it’s really important to identify and discuss your supervisees strengths and their weaknesses. To talk about them upfront before you even start in on developing or as a way to develop that relationship. Learn their style. Are they better visually or verbally? I mean, most of us are really good verbally, or we wouldn’t be therapists, but a lot of therapists are not good in the written form, so how do we help them?

It is important for the clinical supervisor to teach good documentation skills. Unfortunately, most supervisors have the same experience that their supervisees have. They weren’t taught in grad school. They didn’t learn when they had their internships. And they got a lot of conflicting advice. So, they think up the thing that makes the most sense to them, or they rely on what their supervisors told them. And inaccurate or incomplete information gets passed down like a legacy burden from one well-meaning supervisor to another. That’s a problem. And that’s why I think it’s really important for supervisors to learn documentation. Not just think they know it.

Kayla: I love that. If a clinical supervisor is concerned about a supervisee’s performance, how would a supervisor give and document corrective action in their notes?

Beth: Well, that’s a hard one. We all have to document it.

First of all, it may depend on province or state or even federal regulations. In Massachusetts, when we’re having a problem with an employee, we have to document what the problem is. What the solution to the problem is. The timeframe for implementing the solution and whether the therapist implemented it. It’s really like a treatment plan. So that’s what you do. You get very concrete. It’s a very behavioral plan that you come up with. It’s not pleasant except when it works out.

Unfortunately, and I know that I’m not the only one. I’ve had to fire people from clinic jobs. It’s really hard. And it’s really hard to make it as good an experience for the therapist as possible. Because my belief that my job is whatever I do needs to be a contribution to the person I’m working with. I think that that’s our job as therapists. Not to tell a therapist, a supervisee, you’re really bad at this. That’s just so undermining. There are a lot of supervisors, unfortunately, who do it, and I’m sorry that it’s true, but it’s true.

Kayla: I appreciate that. And I think there’s kind of two things here. One, there’s the clinical supervisor who works for you, who’s an employee. And then there’s the clinical supervisee who you know may be paying for your services kind of as an outside clinical supervisor.

And you are exactly right. Like when we think of sometimes there’s this nuance between. You are the person’s boss and you’re the person’s clinical supervisor. And how do you navigate the complexities of letting someone go from an agency job if they are– at least here in Canada, if they are employees, they fall under employment law, which means there’s a whole process you have to take there. If they’re independent contractors, it obviously depends on what’s within that contract and so forth. But that’s very different than of course if you are a external supervisor for somebody as well.

Beth: You’re drawing an important distinction, so I’ll address that. When you are a supervisor working for a clinic or agency, you have to follow the protocols and the requirements of the agency. And you have to enforce what they demand.

Unfortunately, there are some agencies that demand unethical behavior. I’m just going to call it out because it happens. Then if that happens, you have a decision to make. As a supervisor, you have to decide whether you fight it or you don’t fight it. As a supervisor, you have to really look and see how capable your supervisee seems to be able to change, and can that person change in the structure of the agency?

I had a supervisee who really could not make the changes she needed to make. She was not a bad therapist, but she really saw herself more as a coach, and this was not an appropriate fit. That’s okay. There was nothing I could do to help form a new identity given where she was, she needed the identity of as a therapist, wasn’t hers. So, it’s important for the supervisee in a clinic to read the company manual and to know their codes of ethics.

Kayla: Absolutely. Beth, you have a free resource you’d like to share. Can you tell us what it is and how it can help listeners?

Beth: You bet. It’s a free tip sheet called 25 Tips to Getting Notes Done. One of the things that so many therapists struggle with, whether it’s a supervisee or any therapist, is staying up to date on notes.

I know I’ve gotten behind. It happens to the best of us, so I created a tip sheet. Name, 25 Tips to Getting Notes Done. It’s kind of self-explanatory and you just pick a couple and use them. Try them, see what works. There’s a lot of really good tips on there, like, you know what? Try concurrent documentation. See if it works. Doesn’t work for me, but it works for a lot of other people.

Try playing music, when you’re writing your notes. Try writing your notes in a community of other people. It with a structure, because you’re not alone. You’re not really talking, you’re not saying anything, but you’re not alone. So, there’s some really wonderful tips. You try a few, some work, some don’t work.

Kayla: So, to sign up for Beth’s 25 Tips to Getting Notes Done, check out canadianclinicalsupervision.ca/bethrontalfreebie

Or you can simply scroll down to the show notes and click on the link.

Beth, thank you so much for joining us on the podcast today to discuss case note documentation considerations for clinical supervisors.

Beth: You’re very welcome. Thanks again for having me.

Kayla: And thank you everyone for tuning into today’s episode, and I hope you join me again soon on your Clinical Supervisor’s Couch podcast.

Until next time, bye for now.