Guide to Progress Notes

Good note taking helps you counsel. Though we must always be aware of how our notes may be viewed and used by others, we must not lose sight of the fact that the primary purpose of case notes is to assist us in counseling. Progress Notes Progress notes are the official record of what has happened in counseling. This is differentiated between personal notes of sessions that you take that are not a part of the documentation of treatment made available to supervisors and other staff. They describe the content and events of counseling and document your care of the counselee. Progress notes are the core of most clinical records. They provide a record of events, are a means of communication among professionals, encourage us to review and assess treatment issues, allow other professionals to review the process of treatment, and are a legal record.1 Structured Note Format D.A.R.T. (Description, Assessment, Response, Treatment plan) When you think of recording notes it is important to tell what happened, what you made of it, how you responded, and what you plan to do in the future. Style is not important: clarity, precision, and brevity are. Your goal is to record all the essential information in as little space and time as possible. Description: This includes a description of the counselee and situation which should include the when, where, who and what. The when, where and who provide basic information about the issue brought up in session. The what provides your observations about the counselee. Assessment: This is the why of the session. You do not always have to offer profound insights or explanations, nor do you always have to know what something means. Sometimes the most important notes are about behaviors that stand out precisely because their meaning is not exactly clearThe most important task is to give some thought to what you observed and try to relate it to your overall knowledge and treatment of the [counselee]. Response: How did you respond to your counselees words, behaviors, and what you observed? What kinds of questions did you ask? What direction, encouragement, or counsel did you offer? What homework did you assign? What were some reasons to your approach? Treatment Plan: This is a statement of problems, the goal of counseling and steps that will be taken to reach those goals. This helps you to refresh your memory from session to session and keep overall counseling goals in view.

1 This and other quotations are taken from The Internship, Practicum, and field Placement Handbook: A Guide for the

Helping Professions, 5th ed. By Brian N. Baird M. Kim Essential Qualities of a Biblical Counselor, CCEF