Hello, and welcome to Counselor Weekly! Thanks again for being part of the community!

Here's the short and skinny of today's newsletter:

• Meme of the Day

• Weekly Resource

• Interesting Articles

• Common Treatment Note Formats

Until I have an official sponsor, looks like I'm the sponsor!

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Meme of the Day

Using AI for Treatment Notes

Has anyone used some of the new AI technologies for creating notes?

I’m starting to see more and more marketing of AI technology for note taking, but not totally sold on it. Here’s why:

• HIPAA- though they say they’re HIPAA compliant, it still feels kind of odd to have something recording your sessions to produce notes.

• More money- just another service that typically costs $100 a month.

• You still have to review them. Sometimes the time it takes to review what AI wrote might be more time consuming than just writing notes.

• Not sure how it integrates with EHR softwares. These days, most softwares have a super simple note process integrated into the software that is very easy and quick to complete.

Possible Use Case: settings such as hospitals and treatment centers. Many therapists I talk to in these environments report hours of note taking and documentation EACH DAY! Maybe AI can help by recording the sessions and automatically inputting treatment notes, saving time and lowering stress?

Click the Icons Above to Check Out UpHeal and Mentalyc

Headspace Launches All-In-One Mental Health Offering and Expands EAP Replacement Solution

Tech companies continue to invade the mental health space. Not sure if it’s good or bad, but it’s a reality either way.

The Mental Benefits of Random Album Generators

Maybe Taylor Swift on repeat isn’t the best option? Trying new music might be a helpful resource to have your clients (and yourself) implement.

Transtheoretical Therapeutic Change Mechanisms

Well that’s a mouthful!! I really like the ideas in this article that identify the counselor relationship as being the most crucial part rather than diagnosis and theoretical orientation.

Common Treatment Note Formats

If you’re like me, the goal of treatment notes is to complete them as quick as possible and still have all the required information. Thankfully, most EHR softwares have notes imbedded into the software and makes it a fairly efficient process. Here’s a brief overview of the two main types of treatment notes:

SOAP Notes:

- Subjective: This section includes information reported by the patient or client, such as their symptoms, feelings, or concerns. It is essentially the patient's perspective on their condition.

- Objective: This section contains observable and measurable data obtained by the healthcare professional during the session. This can include physical symptoms, test results, or any other objective data.

- Assessment: Here, the healthcare provider analyzes and interprets the subjective and objective information. This is where the diagnosis or assessment of the patient's condition is made.

- Plan: The plan outlines the steps that will be taken to address the patient's concerns or issues. It includes the treatment plan, medications prescribed, and any recommendations for further tests or follow-up.

DAP Notes:

- Data: Similar to the subjective and objective components of SOAP, the data section in DAP notes encompasses both the client's subjective experiences and the therapist's objective observations or assessments.

- Assessment: This section involves the therapist's professional analysis and interpretation of the information gathered. It includes the diagnosis or assessment of the client's mental health status or progress.

- Plan: The plan outlines the therapeutic interventions or strategies that will be employed to address the client's needs. This can include specific counseling techniques, goals for the next session, or referrals to other professionals.

 Example of a DAP Note:

Data: Client reports increased feelings of anxiety and difficulty sleeping. Observed fidgeting during session.

Assessment: Aggravation of generalized anxiety disorder symptoms.

Plan: Implement relaxation techniques, discuss coping strategies, schedule follow-up in two weeks.

Both SOAP and DAP formats are commonly used in mental health settings to document patient or client encounters systematically. The choice between them often depends on the specific requirements of the healthcare institution or the preferences of the healthcare provider.

My preference: less is best. Complete notes based on your licensure requirements, but don’t overdo it. Also, if you ever receive a request for records (which you probably will), your client will be able to read everything you wrote. Keep it simple, and to the point.

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