Progress...Noteszzz...

What is a tactful way to record that a client repeatedly fell asleep during an appointment?  Poor person fell asleep while I had her at the psychiatrist, slept while I drove her home and fell asleep on her feet while I was speaking to her mother afterward!

You know it's bad when...

...you are writing case notes and keep thinking you have put information from the wrong appointment because you're pretty sure this stuff just happened yesterday.  Which it did, because for once you are up to date on your notes.  And it feels so wrong!

This Week Sucks Because....(drumroll please)

1. I have only completed 2 out of 9 assessments that are due shortly (usually we only have 1 a week)
2. AM is away so I'm lonely and looking after kiddo by myself
3. I've got a vicious head cold
4. It's cold outside (there was snow yesterday)
5. I haven't written any of my notes for this week yet, and still have some from last week to input
6. I can't even say TGIF because I am going to have to work from home this weekend to catch up
7. I also have to survive taking a car load of obnoxious noisy excited kids to the Santa Claus parade

*whine*bitch*moan*complain*

Thank you, internet, for being there for me.

Vacation Countdown

20 notes
3 phone calls
2 client visits
2 assessments
1 consult
And 7.5 hours are all that stand between me and a glorious 5 day weekend!

Facts and Feelings

"[Client] has a daughter [name] who is in the care of [client's] mother in Thunder Bay. [Client] reports having no contact with his daughter, and states that he does not wish to have contact. [Client] has indicated that he thinks she is being well looked after and does not wish to disrupt her life."

This man's wife committed suicide in 1999.  She had schizophrenia, as does he.  I suspect any reminders of her are just to painful.

Sometimes when I stop to actually read what I record in my notes it just makes me sad.

When Spell Check Doesn't Help

Note to self: when recording how a client copes with their symptoms of depression, there is a big difference between "medication" and "meditation."  While both could potentially be effective, be sure to pick the right one.

Whoops!

Suggestions Needed!

Is there a proper term for the buzzers in apartment buildings? The other day I caught myself writing this in my client notes: “I buzzed Charles* unit, but there was no response.”

Uh, that does NOT sound right. I changed it to “I buzzed Charles apartment” which is definitely an improvement, but I’d still rather use another word! Since I tend to rely on repeating simple phrases as a way to make my note writing go more quickly, I can’t help but wonder how many times I’ve written that sentence in other client’s notes. Oh dear.

Help, anyone?



*obviously not his real name

Cloudy Day

Inspired by this post over at Social Work Blogs, I decided it would be fun to make a Wordle of my own. I decided to use my client notes for the month of September.

A couple things I found interesting. The words that turn up frequently in my notes seem very formal: scheduled, meeting, information, reported. If I were to do a wordle of the words and phrases often used to describe mental health work, I bet it would look very different. Also, I decided about half way through the month to break my habit of using “client” instead of a person’s proper name. It’s an out dated practice, and a bit of a hang over from when I used to write notes in third person. I’ve gradually been shifting out of that mode since I did a bunch of legal & documentation training where I learned that it’s really not necessary, and often confusing. If I took notes from any previous months, the words Client and client would have been twice as enormous. By the same token, I learned at that training that “stated” is a valuable tool, because it makes it clear that you are not directly quoting the person, and also that you are reflecting their own ideas and not imposing or assuming anything. Obviously, I use it a lot.


The prevalence of certain words reminds me just how much I rely on a certain set of phrases and terms to help me get through my notes quickly, and hopefully write them in a way that will be clear to others.

I could go on a lot more, but I realize this analysis probably a lot more interesting to me than any one else! Identifying information has been removed, natch.

Clarity is Key in Client Documentation

from a client’s hospital records, 1988

“Her answers are somewhat vague 30% to 40% of the time.”

How very precise.

Yay!

Sound the trumpets! Start the parade! My notes are done and UP TO DATE!!!!

Now if only I could say the same for my assessments, grr....

aaaand, she's off!

and today starts with....(drum roll please) paper work. of course. at the rate these hospital records are coming in, I won't have time to meet with another client until 2014!