In all my time as a psychotherapist both in community health and in private practice, I know that progress notes are important to capture especially right after a session. But we often find ourselves racing against time to complete documentation right after client sessions because I probably only have about 15 minutes. I use a few different methods to write my progress notes (templates, cut and paste shortcuts and AI) but I recently started using my voice to record notes. One of the benefits of using your voice is that it's faster than typing, helping you reduce your overall documentation time.
I typically already have a notes template with Subjective, Objective, Assessment and Plan (SOAP) formatting on a table so I can easily go from one to another. On my Mac, I just press the voice button and speak into my mic (or headset) and discuss the session, usually right after the session is over. Since I work from my home office I have a private place but this may not be optimal for those working in busier offices. You can capture rich details about the client's presentation, interventions used, and their response to treatment.
You can structure your notes using the SOAP format:
Subjective: "Client presented with improved mood..."
Objective: "Maintained good eye contact throughout, affect was congruent with mood..."
Assessment: "Client used CBT techniques to talk back against cognitive distortions..."
Plan: "Will continue practicing thought records, next session scheduled for..."
Eventually, you may have certain sentences pre-typed out that you can just use as a guide. This is step 1 of my 4-step plan for efficient note taking that I have developed. Other steps to come in future posts.
Have you tried using voice notes for clinical documentation before? I'm curious to hear about your experience with different documentation methods.
What AI tool do you use for that ?