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Writing a good progress note in a patient's chart is a learned
skill. It is not natural to write progress notes. It is more
within the realm of human creativity to write poetry, stories
and songs. Progress notes are more difficult because we
are trying to describe a therapeutic interaction in concise
technical terminology.
Because of the
clinical and grammatical skills involved in writing notes, I
used to think that workers who wrote poor notes simply
lacked these skills. You know, some people excel in verbal
communication and some in written communication and never the
twain shall meet. However, skills can be learned, at
least to a point of satisfactory application.
So, why do some
clinical workers write generic notes? I'm not talking about
the minimalists who write the bare essentials of a session.
I'm not talking about those verbose beings for whom writing
seems like a compulsive activity. I'm referring to workers
whose patient charts read like clones of one another. Their
treatment plans and psychosocials are nearly identical. Their
progress notes make the session sound like it never happened.
Some clinical
workers just seem to develop a tendency toward the generic.
It is as though if you have seen one patient you have seen
them all. The same diagnoses are repeatedly given: perhaps
because the patients really have these diagnoses, or perhaps
because the worker is comfortable with only a limited number
of diagnoses.
There seems to
be a certain career burnout, a diagnostic cynicism, and a
treatment hopelessness on the part of these workers. They
seem to have given up on their own patients. Perhaps they
have lost their original motivation for becoming professional
helpers. Their workday has become a blur of shuffling papers
and a haze of faces sitting in the chair across from them.
Some people may
not be temperamentally suited for clinical work. Helping
others is not glamorous. Often, it is not even rewarding. It
requires maturity, compassion, constancy, and the ability
to set aside oneself for the sake of others. Without sources
of support and nurture outside the job, the mental health of
the worker can be at risk. Any kind of social work also seems
to have a spiritual dimension to it in that it is a mission
as well as a career. Remaining spiritually focused may be the
only real way to procure worker constancy.
People are not
generic. Our patients are unique individuals who invest a
great deal of time, money, and trust in us. They deserve a
decent progress note. I dislike paperwork as much as anyone,
but I have to admit that writing notes helps me to
conceptualize and plan. Progress notes, psychosocials and
treatment plans are meant to be useful. Perhaps the basic
problem with paperwork is the redundancy of it and the number
of forms that have to be filled out for other purposes such
as insurance reimbursement.
Bureaucratic
skills are necessary for success in social work. Our
effectiveness is judged by how well we put together our
charts. Nobody sees the work we do when in session with a
patient. The therapy session, the patient's progress, goal
formation and achievement have to be given a written
reality. Then, bits and pieces of that already written
expression have to be duplicated or modified to fit insurance
forms, monthly reports to referent agencies, discharge
reports, quality reviews, and other various needs.
Not all
paperwork is equal. Some of it is useful, and some of it is
imposed. Whatever our feelings about it, it requires careful
attention. It can also be a method of self-protection. Our
notes are all that we have to document the steps we take to
provide care, as well as to document the patient's acceptance
or refusal of our interpretations and suggestions. A good
progress note could turn out to be the antidote to a
malpractice accusation.
Hopelessness is
probably a triple-edged sword. There seems to be a
hopelessness that patients can really get well and stay well,
a personal hopelessness that the therapist can really be
effective, and another hopelessness that the workplace can
become truly manageable. People who experience the first
hopelessness need to re-evaluate their career choice because
their feelings can be contagious and result in self-fulfilling
failure for their patients. People who experience the second
hopelessness need to re-vitalize their education and get
support, or perhaps stop indulging in egocentric insecurity.
People who experience the third hopelessness need to, well,
carry on. (Written 02/03/03 - Revised 12/01/03)
Until we meet
again....... .......stay sane.
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