⚖️Can Note-Taking be a Collaborative Process?

Last week, I wrote about client requests for therapy notes and the benefits/concerns linked to it.

One way of opening therapy notes to clients is through Co-Documentation, a process that supports them to take an active role in the therapy process. Additionally, some people have found it helpful in working through an impasse in therapy.

Albeck and Goldman (1991), a therapist-patient duo wrote about a client-therapist co-documentation format that was initiated in their sessions together. Here are the steps they outlined-

1. Patient and therapist agree to share responsibility for documentation of treatment.

2. During the last several minutes of each session, the patient records, by dictation, their views about the important issues covered, while the therapist listens.

3. The therapist can then dictate their comments in the presence of the patient.

4. The notes are transcribed from tape recorded to written form between sessions.

5. The typed transcriptions are available for joint review by patient and therapist during subsequent sessions.

Albeck and Goldman (1991)

The time for discussion in the next session- allows to work through any disagreement the therapist and client have in their notes- and can be a therapeutic experience. This process would specifically capture the ‘session content’ part of the SOAPS format, leaving Assessment and Plan to be filled out by the therapist by themselves.

If you have tried this/something similar I’d love to hear your experience! Just click reply and write to me.

To read more about Albeck and Goldman’s (1991) journey, check out this paper-

Patient-Therapist Co-Documentation.pdf1.79 MB • PDF File

Until next week,
Suvrita

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