Wave of Consciousness, "A Voice of Sanity in a World of Conflict"

No Generic People

by Natalia J. Garland, M.S.W.

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)