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ChatGPT for Therapy Words to Help Write SOAP Progress Notes

Dec 01, 2023
words for therapy notes AI ,Chat GPT for therapists

 Just when you get done with your final client after a long day of processing feelings, analyzing the transference and externalizing problems, you realize that you've got all those notes to do. Your heart sinks, your brain goes blank and you can't even remember the name of your first client, much less what interventions you used and how to describe their affect.

Sound familiar? 

Process notes I can handle, are more private notes and I don't have to think as much. Progress notes, however, are clinical notes and as such are the bain of my life, aside from a brief period of my life in which for two glorious days a week as a Clinical Director, I didn't see any clients as I was busy, y'know, directing the clinic and such. Now that I'm simply a licensed marriage and family therapist in private practice all the time, I'm back to the slog of trying to remember words, interventions, and what the A in SOAP Notes stands for.  

 

How Do You Write Psychotherapy Notes Quickly?

Well, clearly, I don't know the answer to that, but I did have a brainwave the other day while walking my dog, which is when most of my ideas seem to pop into my head. I don't think there's a shortcut to doing them; they are of course, important medical records, so we do have to make sure we are documenting a therapy session. According to CAMFT, the California Association of Marriage and Family Therapists, Therapy Progress Notes.

" brief, written notes in a patient's treatment record, which are produced by a therapist as a means of documenting aspects of his or her patient's treatment. Progress notes may also be used to document important issues or concerns that are related to the patient's treatment."

You should check with your own state laws to make sure California isn't wildly different. 

I do like that it says 'brief' there because a lot of my supervises (you know who you are) have masochistic tendencies to write enormous essays outlining details that are truly interesting but completely inappropriate for notes. So I do spend a lot of time telling new therapists to keep things brief, but obviously, I can't advice you on how brief they should be because one insurance company will have different needs over another. 

Falling Behind On Your Psychotherapy Notes? I've Got Your Back... Possibly.

Therapy Progress Notes suck because you have to change mental modes of thinking and being, and at the end of the day, that is a tall order. As a therapist, we are in one mental state, listening, thinking, feeling and conversing with our clients. Then they leave, and we take off therapy mode and hopefully go back to ourselves. That's a shift into a different state of mind and thinking, and for every client you see, you shift in and out of mental states, which takes a toll, and that's why you're so exhausted from just sitting down all day. 

Doing our therapy notes at the end of the day requires one more shift into an entirely different way of thinking, which is the language of clinical documentation and that sterile language that we have to write in to meet insurance requirements. It's this final shift into yet another way of thinking that puts many of us off from doing a note, a treatment plan or any mental health documentation actually. 

a ChatGPT for Therapy Notes Trainer/>

A Personal Trainer For Your Psychotherapy Notes

I decided that what some mental health professionals need is a personal trainer for an electronic health record! Not one that yells at you, like Barry (who I adore and is the best trainer ever) but more like a Soul Cycle Spin Instructor. Y'know the one who is all motivational and spiritual as they make you peddle faster?

"You've got this! You can do it- oh wait, remember your posture." 

"You know what's next right? Yup - "ASSESSMENT" 

"Come on, Oliver. Do you know what therapeutic intervention you used? Did you 'explore feelings?' or did you 'probe for more affect?"

Come on! Which is it? THE WHOLE OF YOUR CAREER DEPENDS ON THESE MENTAL HEALTH PROGRESS NOTES" etc etc... 

Is Finding The Right Words For Notes A Challenge? - an AI Cheat Sheet To Help

Here's some good news, I think.

I am by no means a programmer or tech expert, but I have been dabbling in artificial intelligence, as you might be able to tell if you've spent more than five seconds on my website. When Chat GPT announced you could customize your own GPT's I put my problem-solving skills to use on the task of curing my loathing of client notes. I think I had a good idea, and possibly a great idea, to program a GPT with all the important details, use of language and a whole lot of therapy words clinicians have unique needs for. Consider it a cheat sheet powered by Open AI?!

Click here to find the ChatBot  The bad news is that you might have to be a GPT Plus member, sorry.

Here's some tips on how to use it:

  • If you're a therapist literally, any way that you can make your note-writing more efficient and personalized by creating an interventions cheat sheet can be a game-changer. You can use this chatbot to help in your process of creating a cheat sheet and provide you with some sample interventions OR you can use it every time you write a note. 
  • It's important to note that using your own therapeutic interventions cheat sheet is recommended over using someone else's, and definitely over this ChatGPT - I gave it very strict instructions to only use the words I provided, and I only only know so many. I am hoping that it doesn't start making things up, but that is a legitimate risk AI at the moment. Take the words it gives you as inspiration to tailor the interventions to your own practice and avoid using these random words that may not be relevant to your clients.
  • This chat is going to take you through each part of a SOAP note, and will prompt you several times in each part. The idea is to use each answer it gives you as a prompt or a pattern rather than just a single phrase or word. Obviously it doesn't know what you did in the session, and you should ABSOLUTELY NEVER tell it anything about your clients - it's the health insurance portability act worst nightmare. 
  • Take the answers it gives you and personalize each - I've set it up so that it's basically giving you an incomplete sentence and your job is just to complete it, so be sure to make your notes read like full sentences. 
  • While this may seem time-consuming, having an AI cheat sheet will actually save you time in the long run because you won't have to rethink and rewrite different interventions for each session.You won't be struggling to remember the format or think of clinical words, because it will offer you a selection. 
  • Make sure each intervention specific and meaningful. Avoid copying and pasting the same intervention over and over again - and I've programmed it to have over 400 words and to give you random options each time. Instead, highlight how each intervention played out during the session with that particular client. This will make your notes tell a story and provide valuable information for future reference and comply with the ethical and legal requirements we have under the BBS.

Here are just some of the things the Chat GPT will guide you through - I'm adding to it constantly so let me know if you think it needs more and in what areas.

Subjective

  • Primary Concern
  • Themes of the session 
  • History

Objective

  • The Client's Presentation, Affect etc. 
  • Mental Status

Assessment

  • Evaluation
  • Assessment
  • Concerns

Plan

  • Interventions
  • Impairments 

Frequently Asked Questions About Therapy Notes

Can Insurance Companies Request Therapy Notes?

The simple answer is yes, they can. Insurance companies may request therapy notes for various reasons, such as reviewing services for approval or investigating red flags in billing habits. It is important to inform clients about this possibility and obtain their consent to release records to insurance companies if requested. Clients have the right to decide whether they are comfortable with insurance companies accessing their therapy records.

 How Quickly Do I Have To Write A Therapy Note?

The second question pertains to the timing of therapy note completion. While some states may have specific guidelines, most do not. It is generally recommended to complete therapy notes within 24 to 48 hours to ensure accuracy and ease of documentation. Medicare and Medicaid often have requirements for notes to be completed within a certain timeframe, typically 24 to 48 hours. It is important to check your insurance contracts for any specific requirements. If you are part of a practice, it may be beneficial to establish guidelines for note completion.

How Do You Write Clinically About A Client Crying?

The simplest way to document this is by stating "Client became tearful" is my go-to for this one.  Or "client cried." Sticking to observable facts and avoiding making assumptions about the client's emotions or reasons for crying is important. Maybe they were crying because they were sad, or felt abandoned, but that is not necessarily information insurance needs, so 'crying' is a better option.

Depending on the situation and the client, I'd be very curious to ask what the tears meant or what the feeling was - I'm big on turning thoughts and feelings into words, not actions, and crying is an action of sorts. Their answer is a little unecessary to provide an explanation in the documentation. The fact that the client cried is sufficient information to include in the progress note.

 

Can You Put Client Quotes In The Therapy Note?

Client quotes can be included in the therapy note, but ask your self WHY you are putting it in there. I think most things can be written as a statement without using their words and that's what we should be aiming for. If you do use their words, put it into quotes, and make sure you're using it only to provide valuable insight into a specific thought, feelings, or experience that is relevant. 

 

What goes into a therapy note?

1. Overview: When writing a therapy note, it is important to include a comprehensive overview of the session. This includes documenting the topics discussed during the session, such as the client's concerns, challenges, or any significant events that were addressed. It is also crucial to include the interventions used during the session, detailing the specific techniques or strategies employed to support the client.

2. Presentation:  the therapist should document the client's presentation and response throughout the session. This includes observations about the client's mood, affect, behavior, and any notable changes or patterns that may be relevant to their progress.

3. Assessment: Include an assessment of the client's progress or lack thereof. This could include test results but really is just about the healthcare providers assessment. This involves evaluating whether the client has made any improvements, setbacks, or if they are experiencing stagnation in their therapeutic journey. It is important to be objective and provide specific examples to support the assessment.

4. The Plan: Outline the plan moving forward. This includes outlining the goals and objectives for future sessions, as well as any strategies or interventions that will be implemented to address the client's needs.

5. Optional: changes in the treatment plan, test results, new information, new diagnosis, SI increases or decreases. 

6. Consultations: if there was any interaction with outside bodies , such as family members, caregivers, or other professionals involved in the client's care, this should be documented as well. This includes any communication or collaboration that took place and the outcomes of those interactions.

 
 

The Legal and The Ethical 

The Importance of Documenting Competent Treatment

One of the primary functions of progress notes is to chronicle the quality and nature of the treatment provided. A good note will act as a window into the therapist's approach, showcasing their clinical judgment and adherence to professional standards. Imagine trying to understand a story without its crucial chapters; that's what a treatment record without progress notes would be like. Notes also contain basic information about the type of therapy you're doing relevant information about the client and treatment goals and of course CPT codes so insurance can pay you. These notes are particularly valuable in complex cases, offering insights into how a therapist navigates challenging scenarios and manages a patient's symptoms. Best practices require us to write them as a safeguard, ensuring that the therapist's actions remain ethical and lawful, especially if questioned.

Highlighting the Necessity of Treatment

Progress notes also play a key role in demonstrating and explaining important information why a patient needs treatment at a specific time. For instance, insurance companies often require proof of 'medical necessity' for treatment, and progress notes effectively fulfill this requirement. In California, for example, state-funded treatment programs are regularly reviewed to ensure that medical necessity is clearly documented in these notes.

Facilitating Effective Treatment Planning

Therapists often refer back to progress notes, especially when there's been a significant gap between sessions. These notes help refresh their memory and provide continuity in treatment, particularly in settings where a patient might see different therapists. They ensure that each therapist is informed about the patient's progress and the effectiveness of previous interventions.

Ensuring Accurate Billing and Payment

In situations where there's a dispute over billing, progress notes come to the rescue. They provide undeniable proof that professional mental health services were provided, detailing the nature and extent of these services. This helps in maintaining transparency and trust in the billing process.

Meeting Legal and Ethical Standards

While there's no one-size-fits-all format for progress notes, therapists are guided by general legal and ethical standards in clinical record-keeping. In California, for example, the law provides therapists with some flexibility but also expects them to maintain an official record of the session that reflects sound clinical judgment and professional standards. Failure to do so can be considered unprofessional conduct.

Introduction to SOAP Notes

SOAP notes are a structured method of documentation used by healthcare professionals, including therapists, to capture detailed information about a patient's treatment. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, each representing a crucial component of the patient's record.

Subjective: The Patient's Perspective & Subjective Statements

The 'Subjective' part of SOAP notes is where the therapist records everything the patient expresses, direct quotes are appropriate here. This includes their primary complaints, mood, stressors, and how they describe their problems. It's essentially the patient's narrative of their experiences and feelings, providing valuable context for their treatment.

Objective Data: The Clinician's Observations

The 'Objective' section is where the therapist notes their own observations. This can include the patient's orientation to time and place, grooming habits, affect, interpersonal style, and speech patterns. For example, does the patient speak rapidly, softly, or with pressure? Are they avoiding certain topics? These observations offer an objective lens through which the therapist can assess the patient's condition.

Assessment: Clinical Impressions and Insights

In the 'Assessment' part, the therapist synthesizes the subjective and objective information to form a clinical impression. This involves identifying nuances in the patient's behavior, changes over time, and contextual factors. The therapist may note clinically significant behaviors, attachment styles, or compensatory behaviors, all contributing to a comprehensive understanding of the patient's state.

Plan: Mapping the Way Forward

Finally, the 'Plan' section outlines the next steps in the patient's treatment. This could include future interventions, homework assignments, mood tracking, or skills development. For psychiatrists, it might involve medication regimens and monitoring for side effects. For therapists, it could focus on specific behavioral targets or therapeutic techniques to be explored in future sessions.

 

Frequently Asked Questions About Therapy Words For Notes:

1. What therapy words should I use in the SUBJECTIVE part of a SOAP Note?

Client presentation: appearance, demeanor, communication style

Presenting concerns: chief complaints, goals in own words

Emotional affect: descriptive terms for emotional state

Thought patterns: self-reported thought patterns, cognitive distortions

2. What therapy words should I use in the Objective part of a SOAP Note?

Mental status exam: orientation, memory, mood, thought processes

Behavioral observations: noticeable behaviors in session

Testing results: relevant test scores or assessments

Diagnostic codes: DSM-5 codes based on assessment

3. What therapy words should I use in the ASSESSMENT part of a SOAP Note?

Differential diagnosis: ruling out alternative diagnoses

Functional impact: how concerns affect overall functioning

Cognitive patterns: maladaptive thought patterns contributing to distress

Behavioral patterns: observable patterns influencing well-being

4. What therapy words should I use in the PLAN part of a SOAP Note?

Treatment goals: specific objectives for therapy

Therapeutic interventions: techniques or approaches to be used

Referrals: recommendations for other services or providers

Follow-up plan: scheduling future appointments or check-ins

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