“Any note is better than no note.” In today’s episode of the Colleague Down the Hall podcast, Dr. Maelisa McCaffrey joins me to talk about her expertise; clinical documentation in therapy work. She discusses the challenges therapists face when it comes to writing treatment plans and progress notes. She delves into issues such as getting behind on progress notes, lack of confidence in note-writing and not understanding the implications of certain documentation choices. She provides practical tips for therapists to improve their documentation, including the key components of a progress note and the need for customization based on individual needs and legal considerations. She also touches on the use of AI in private practice.

The goal of this episode is to normalize the challenges therapists face with clinical documentation, review the basics that need to be in every progress note, provide guidance on common mistakes, encourage therapists to approach documentation with confidence and practical strategies, and explore the use of AI in private practice.

“If you're going to have a private practice and do this stuff on your own, you have to be willing to take a little bit of that extra step. A little extra time to review those things and make sure that it is personalized to you and same with note templates. I see so many people who are like, you'll hear people say, you know, I thought I was supposed to put this in a note, and I thought I was supposed to put this in a note, and someone told me this or when I worked at this agency or this group practice, we had to write our notes this way. 99% of those are arbitrary guidelines. There are very few guidelines around what goes into note and so it does require a little critical thinking about one - what should go in and out for you based on your clients in your profession, but also two - what's helpful, what's useful.”- Dr. Maelisa McCaffrey

The key highlights:

• The importance of understanding the "why" behind documentation recommendations and thinking outside the box while maintaining ethical standards.
• The impact of the pandemic on increasing the number of therapists seeking support for documentation issues.
• Addressing the common struggle of therapists feeling unprepared due to a lack of training in documentation during graduate school.
• The stigma and stress surrounding documentation issues, creating a cycle of shame in the profession. Therapists often feel hesitant to seek help or admit their struggles with documentation due to fear of judgment.
• The common mistakes therapists make, including being behind on paperwork and lacking confidence in their notes. 
• The lack of specific guidelines for documenting and decision-making in the gray areas of therapy work.
• Specific tips for more efficient and effective progress note writing. The insights on AI adoption in private practice.

About Dr. Maelisa McCaffrey:

Dr. Maelisa McCaffrey is a licensed psychologist, nail design enthusiast, and multi-passionate entrepreneur. Through her business QA Prep, she empowers therapists with trainings and consultation on clinical documentation. Maelisa focuses on the “why” behind the usual recommendations and encourages clinicians to think outside the box, while also keeping their ethics intact. As someone with ADHD who’s had to figure out what works through trial and error, Maelisa aims to make sure her trainings are practical, while also allowing for plenty of laughter and fun.

Connect with Dr. McCaffrey:

QA Prep website: https://www.qaprep.com (Sign up for the FREE Private Practice Paperwork Crash Course) 

YouTube: https://www.youtube.com/channel/UCytXRIFI17MtbmTh5QTJhsg

Connect with Jeanene:

*Get your free Four Keys to Private Practice Peace of Mind workbook: https://collaboasis.com/4keysworkbook

*Join a clinical consultation group: https://oasisfortherapists.thrivecart.com/enrollment

*Learn more about clinical consultation groups: https://collaboasis.com/

*Join my free therapist Facebook group: https://www.facebook.com/groups/oasispcgt

*Connect on LInkedIn: www.linkedin.com/in/jeanene-wolfe-lcsw-64042220a/