Expert: Jacqui - 7/15/2009

Question
Hello,
I am working in a Methadone clinic for the very first time. I have a background in healthcare, but not as a counselor.  I am about to finish my Masters as a Substance Abuse Counselor and I am so very happy.

This is my issue. All of my classes have done a really good job of providing me with the education regarding drugs etc. But now one has helped me with writing notes. Since I stared working I read others notes and I have already made a decision that I want that part of my job to be my strong area. Help me find a good source.

Answer
Hi Linda,

Great to hear you are working in the sector!  

I must admit that I do understand what you mean.  I have worked in the drug sector (primary health care services from a harm reduction standpoint) for many years and am also in the process of finishing off my Masters in Clinical Psychology, and in neither have I been taught much about note taking!

As I work in health, I work with a lot of nurses.  One of them, who is an amazing clinician, uses the SOAP model - Subjective, Objective, Assessment, Plan - which is quite useful in some settings.  Here is a link that I found on this model
http://www.meded.umn.edu/students/residency/documents/06_Keenan_Review_SOAP_Note...

I believe that you could use this model for counselling, although you may need to adapt it a little as it is generally used in medical/nursing assessment.  I am actually probably not the best person to ask as I am guilty of often writing too much, in the fear that I am going to forget something important and offend someone.  The main thing about note taking though, is that they are neat and clear, they are signed and dated, that you don't black things out or use 'white out' (if you need to go over something you simply put a line in it, and initial nearby).  Also, of course, you need your details (including professional registration, title) and the client's details.  I always like to be client focused, and include client stated aims.

If you are working from a Cognitive Therapy model, Judith Beck (I do believe she is the daughter of Aaron, the father of CBT) has quite a good model in her book, 'Cognitive Therapy: Basics and Beyond'.  Whilst this is within her model of Cog therapy, you could adapt it (i.e.: you don't need to use the carbon paper!)   

As far as structure goes, in my psychotherapy practice, I use sections such as "debriefing" where I detail what the client tells me about their previous week/s (since last visit), then "treatment" (detailing what we did), then "homework or plan".  If doing a Mental State Exam, I use the traditional subheadings (if you do MSEs you will know this, if not, no need to worry as you won't be doing them).

A couple of other points are: - if a client tells you something, say "client stated that they had been struck on the head by Fred Smith", as you can get into difficulty if you state that something actually happened (i.e.: by saying something like: client was struck on the head by Fred Smith"), because unless you see something with your own eyes, you don't know it is a fact.  Also, if you are making judgements about someone's health (mental or otherwise), you need to be descriptive, rather than make judgement calls.  For example, instead of saying "client was drug affected", you could say something like "client displayed symptoms consistent with being drug affected, such as slurred speech and falling asleep in mid sentence."    Most importantly, avoid using any kind of judgment - which can be hard sometimes.  Instead of "client was happy", say "client appeared happy".  And of course, avoid things like "the client is a big fat psycho!", (perhaps ... "the client appeared to be a somewhat overweight man, who appeared to demonstrate limited empathy"!)  If it is difficult to describe your perception, documenting what the client actually said often communicates things well.

Of course, I am sure your clients will be much less two dimensional that I have stated above!  In fact, in re-reading my notes, I sound like a bit of a tyrant but I don't really think my clients are psychopaths!  I actually really like working with this client group, and I am sure you know about harm reduction being from NYC - which is of course, a non-judgemental model.  Most of the clients I see aren't big fat psychopaths!

I hope that I have been of some help.  It is nice to hear from a fellow clinician!  Let me know if I can provide any more information.  If not, give me an update on how your new job is going in a few months.

Kind regards,

Jacqui