Two simple and useful templates for each psychologist: what to write during the session
To record or not to record anything directly at the session is a personal matter of each practicing psychologist. How convenient. Some write on a tape recorder, for example. Are you recording?
When psychologists work in a team (in an institution), they just have to keep such records and all. I believe that the psychologist, working individually, also need to keep records on the case of the client. Let after session, but necessarily. Why-read below.
At the beginning of the practice I wrote a lot right in the sessions, but pretty quickly I got tired of carrying notebooks. I began typing the notes into the Appendix. It also got over time. Then I decided to photograph the records in the application. Then I got tired of it, because it was useless :)
Of course, as you gain experience, you develop the skill to note and remember important things in your mind, without the help of papers. But I am sure that the purpose of taking notes on client cases is not just to develop memory, but something more.
Why keep records
Keeping records helps to better understand what is happening to the customer.
There are several reasons:
* It really helps to structure information about the client and his case, to notice some repetitive details, to assemble a puzzle, so to speak.
* You can track performance and progress (and regression too).
* Help with leaky maiden memory. For example, I somehow uncomfortable to ask the customer "what homework did you have?"You can, of course, pretend that this is a special provocative question, but why?
* Planning for the future. Sometimes the session (or later) the thought occurs that it would be necessary to tell it here or to talk about this, where else to write these things, then time to find?
* If you attend a supervision-intervention, or transfer clients to other therapists, then such records are very popular.
• After all, why do doctors always keep medical records? I guess that makes sense.
How to keep records
I hate wasting time. If I do something, it should benefit me. When I photographed notes from sessions in the program, over time it became clear that it is inconvenient to look through them and to look for among them "what he there such important told at that time about a source of a problem, in his opinion?"This photographing turned out just as unnecessary and useless movement for show.
Over time, I realized what specific information I need to record, how to structure it and how to use it later. In the end, had 2 own template for the primary session and to re — and they are designed in such a way that help me to collect all thoughts in the bunch. After some customers, this seems to be a particularly useful thing. :)
Now I write down a lot, but I do not sit with my face buried in a notebook. Always under hand bond, and after the end of the session fill in cards, so say, on fresh head.
Template for primary session
During the first meeting with the client it is important for me to fix:
* source of the request (recommendation, Internet search, etc.))
* request, goals, expectations
* disturbing symptoms
* biographical information (born/married)
* history of "illness", medication, previous experience of psychotherapy, the internal picture of his condition and its causes
• my assumptions about typical trigger situations, automatic thoughts and beliefs, if any, surfaced in the first session
* interventions (if any)
• homework probability
* feedback, well-being at the end, changes in condition
Of course, it's easier to write it down on paper and not hope that you will remember everything.
Template for repeat sessions
This form is much shorter, but the meaning is the same: fixing the main important points and bringing thoughts in order.
What is important to record in repeat sessions, in my opinion:
* changes in health, thoughts and behavior since the last session,
* agenda, aka interventions at the session
• detection of automatic thoughts, beliefs, and trigger situation
• homework probability
* plans and ideas for next time work
• client's well-being / feedback at the end of the session