Are You Making These Mistakes In Writing Your Case Notes & Evaluations?

If you haven't encountered it yet, you will. The request to write a professional evaluation, or to surrender notes, for the purpose of integration of care or consideration for disability, work absences, or child protective services, among many other things. 

When this happens, we have two responsibilities in tension. One is to fulfill the requests that have basis in legal or client-related needs.  But the other is to govern what is best for the client, within the perspective we have of the potential damage it could do. We have to strike that balance between supporting the client in making their own choices no matter our opinions on the matter, and making sure they are well-informed and protected from any blow-back.

The reality is, an evaluation by a counselor can play a role in a person's ability to get a job, disability support, and student financial aid. It could affect potential courses of treatment taken by fellow healthcare and helping professionals, and even influence maintaining custody of the client's children.

The bottom line? The client might be asking for something that's actually more potent than they realize. 

Which is why I encourage you to explain the risks and rewards of their petitioning you to write an evaluation or share their records on their behalf. Especially in situations in which they (or you) have no choice, explain the potential positive and negative outcomes of writing this evaluation or surrendering your notes. 

Discuss topics like this: 

• The client may have feelings related to seeing what you've written about them (assuming they do see them.) These could be positive or negative, and lead to over-attachment or rejection of you the therapist, or have no impact at all. 
• You are not going to be in control of what the other party does with the information you share with them, so it's up to the client to determine how the party will protect their information from there.
• You will not be in control of the outcome, despite what you write or what it says in your notes. Unless you are a psychologist, you cannot conduct psychological testing. Unless you are a doctor, you cannot recommend medical treatment. Unless you are employed by CPS, you can't decide how they will rule for the client. This means legally and medically your notes have no deciding power, though they may influence the outcome.* This is important for the client to know, so that they don't automatically blame you if things don't turn out the way they like.
• If your notes are used in legal proceedings, you are not legally allowed to edit or redact information you have already committed to paper. That means that anything you have written about the client might be discussed in open court. If the client is the one requesting the notes from you, encourage them to review the notes before formally requesting to make sure that the client is comfortable with what is written. 
• Whether or not the therapy goals have changed or need to change due to the change in situation. 

Sharing written records, or writing on a client's behalf, is often part of our job. Sometimes (especially in cases of collaborative healthcare) it can be quite beneficial. But the problem I seem to see on a regular basis is that clients assume it will always be universally positive, and that is simply not the case. Sometimes it will, and sometimes it won't.

I found this out the hard way when I was alerted my notes might be subpoenaed for an active court case, for a client who had undergone a sexual assault. Thing was, the court case was for a completely unrelated issue, and I knew the client wouldn't want the sexual assault history to come out in court. 

That's when I developed the policy of requiring clients to check whether or not they were involved in a court case on their intake forms. That way, I could explain the benefits and drawbacks of including our treatment in the court proceedings before it ever became an issue. 

In addition to being proactive and discussing the situation with your client as shown above, you can greatly minimize negative impact of clinical evaluation and note requests by following two basic guidelines in your regular practice of documentation. 

Follow the principle of MNI: Minimum Necessary Information.

I know how hard this is...my drive is towards facilitating understanding in others, which often means thorough explanations. But in the written word, you do not have at hand the same nonverbals as you'd normally use in speaking to support the meaning you intend. 

It's easier to misinterpret. It's also easier to loose secrets that don't need to be revealed by you. You want to write enough down that you will remember, but consider the difference between something like this: "Cyndi used to write the name of her math teacher Mr. Sorenson over and over in her notebook and draw their names together in hearts" versus something like this, "Cyndi shared she used to have a crush on her teacher." Which would Cyndi rather have come out, if those notes would ever be shared with others?

Ask, "Who Needs To Know?"

We feel compelled sometimes to write detailed notes simply because that was what happened in session. But here's the thing. Why is that a reason? 

We write case notes for a few reasons:
1) To provide reminders for ourselves of past session work and guide ourselves in future treatment planning.
2) To document that service was provided and interventions were offered to help the client with their situation.
3) To provide a clinical record in the case of another professional taking over treatment with our client.
4) To detail treatment for the client, should they ever request their clinical notes. 
5) By default (though not by design) to provide evidence of a client's mental state for the purposes of determining the status of a non-counseling case. 

So I encourage you to ask, when you're writing a case note - who needs to know?

If the answer is not: 

• You.
• The client.
• A fellow healthcare professional.
• Someone determining client status, such as custody, commitment to treatment, governmental benefits, etc.

Then consider whether or not to even write it. Please note: I am not and will never suggest you leave out important, relevant information from your case notes. That would be unethical and possibly illegal. Instead, I refer simply to trimming the fat.

If you plan for the eventuality that any and all of the above groups of people - you, the client, fellow professionals, or a person determining client status - will see the notes at some point, then you will practice cautious writing whether they do end up seeing the notes or not! 

What other questions do you have about best practices in writing case notes & evaluations? Post them below!

*This is true to the best of my knowledge. If you know of a state or situation in which a counselor has deciding influence, let me know.