Note taking is a mixed blessing. It can keep you on track, but it can also be distracting for the client. Also, it can interfere with communication if you are tempted to rest your eyes on the pen and paper, or take copious notes.
At the same time, if you don’t take notes, how will you be able to remember what happened last session? If you are away, how will the alternate counselor know what is going on.
There are also the institutional requirements of the place you volunteer for, are doing a placement at, or work for. They may very well provide a form with strict guidelines.
You can get the “data details” (name, phone, source of referral, emergency contact, etc.) at the beginning of the session.
When the person is actually conveying her/his situation and concerns, you may want to take minimal notes – writing down a few words for each major area – as a memory jog. The real note taking comes later. I encourage you to write up your notes immediately after a session. I like the SOAP method which is used in health care.
In counseling, it becomes SAPO.
Subjective – What the client is describing?
Assessment – What was the ensuing discussion?
Plan – What is the action plan? Remember, there are 23 hours in the rest of the day. Most of the work of counseling is done by the client outside of office hours!
Other – What do you need to do in order to be prepared for the next visit? Is there any info you wish you had gathered or given? If some information is crucial you can always phone or email the client.
Note: While everything you write is confidential, the court may have the right to subpoena your chart(s).
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