There are two types of session notes, known by others as process notes and progress notes. Unless someone can point me to this distinction being used amongst UK psychotherapists, for example, then as a matter of transparency I have lifted these titles from American documents online.
As we are not psychotherapists nor medical personnel I see no harm in adopting these titles because they are so useful. For us, then:
- Process notes are your scribbles during a session and describe what’s going on; the process.
- Progress notes are your neat, post-session summaries of how the client, and the contract, are progressing.
If you take a quick scribbled note at a funny angle during a session, you may need to keep this for five, six or seven years along with everything else in the case notes, especially if that’s all you do. Even if, a week later, even you can’t work out what it says. Check with your insurers. For your own reflective practice as part of your CPD, as well as for easy summary with the client, you may want to also keep a sheet of progress notes that are formatted and legible. There is also the slim chance that an outside agency may need to see your notes, as part of a referral or for other reasons. Its really good to get into the habit of summing up how a session went and what progress was made.
Many formats are suggested as acronyms online and two of these that are very popular, yet really do not suit complementary practice under GDPR, are SOAP and DARP or DAP.
SOAP stands for Subjective, Objective, Assessment and Planning
DARP stands for Data, Assessment, Response, Plan.
Both can be reduced to Information, Information, Decide, Decide, because the implication is that you are in control of what happens at the next session, or in some way able to prescribe and apply some sort of external remedy. It is also best to avoid being subjective at all – never ‘talk about’ your client into your notes, as with the level of service we are at this would be reduced to personal opinion (eg client was difficult, angry, sad, having trouble, poorly dressed). Instead assume your client will read the notes immediately, and stick to what they actually said. That obviously means asking them, and that neatly leads in to the process you apply to your session layout. If you want to recall your own reactions, keep it to a personal journal with no names, and between you and your supervisor.
Creating your easy-fill pre-formatted progress notes sheet.
Knowing that it is a matter of choice to build a progress record and that you could just keep your anonymised process notes, how do you design a standard sheet for progress notes that will a) make the writing-up really easy and b) remind you of all the things you might want to record (or have to record) that didn’t go on paper while you were tapping with the client and scribbling memos to self of names, ages and rooms?
There is no standard format for how to summarise progress in an EFT session. Pretty obviously we all record changes in SUDs, subjective units of discomfort or other measurement units. To make a habit of this also informs your session format. If during tapping a client makes tangential observations about issues in their life that were mutually agreed to be saved for later, then we’d need a note of those. If there was anything else that needed to be picked up at the next session, eg homework, results of homework (if you give it and whatever you call it) then that needs noting too, as do any tools used to assist a client in grounding and leaving feeling safe, or any quotes from the client to indicate their state of mind at the end of a session.
We are also required to record cancellations and no-shows and to make notes every time we have to advise the client to see their GP (and why) and every time we refer them to information about other services, such as giving them a leaflet from the local domestic abuse charity.
Author: Cheryl White, EFT Test Manager