VHG guidance and standards for counselling, psychotherapy and psychology clinical notes.

2. Good practice guidance for counselling/psychotherapy/psychology notes

1. Agenda setting/focus
2. Formulation/treatment planning
   
3. Therapeutic approach
4. Content of sessions
5. Progress review and feedback
6. Relapse prevention and preparation for ending. 

Risk assessment is a distinct area of record keeping and specific guidance on risk assessment is provided here: Risk & Safeguarding Knowledge Base (zohodesk.eu)

Examples of first session and follow-up risk assessments in session notes on MPB can be found here:

Clinical Support | Counselling notes Knowledge Base (zohodesk.eu)

Agenda setting and focus

Notes should show that an agenda/focus for each session has been agreed with the client. The client’s input may be less during an initial assessment session, where the agenda is more structured because of contracting, risk assessment, etc.

Formulation/treatment planning

Some practitioners may use a structured formulation approach and others may be more informal in how they plan with clients. The guidance here accommodates both ways of working. There is a “Treatment Plan” section in the MPB session notes that can be used for this.

1. Therapy plans should show the therapist’s understanding of the problems that have brought the client to therapy, their needs and goals, and how therapist and client will work together collaboratively in support of those.
   
2. Therapists may need to work with clients to identify and prioritise the areas of greatest need for short-term therapy in planning.
   
3. Goals should where possible be SMART, but if a client struggles to define specific goals at first, it may be easier to outline their general needs or the areas they wish to address and try to revisit and refine goals at a later stage.
   
4. The plan should include the modalities, tools and techniques the therapist proposes to integrate and how they will support the client to meet their needs/goals.
   
5. The plan may include tasks between sessions (optional depending on how the therapist works and the client’s preferences).  

Therapeutic approach

1. Notes should demonstrate appropriate therapeutic approach(es) for the client’s presenting issues, needs and goals.
2. There should be a clear rationale for the therapeutic approach(es) outlined in the treatment plan
3. When using multiple approaches/interventions, the types and number should be appropriate and realistic for the duration of therapy. 

Content of sessions

1. Notes should adhere to the general guidelines as outlined here: VHG clinical record keeping good practice guidance for all network therapists (zohodesk.eu)
2. Notes should be factual and neutral, reporting the key themes or issues discussed and using the client’s words/phrases as much as possible.
   
3. Conversations about boundaries and limitations of therapy, such as attendance, extensions, etc, should be recorded in session notes.

Progress review and feedback

1. Notes should show the therapy and the client’s progress are being reviewed regularly. 
   
2. Adjustments to formulations/plans based on client feedback and reviews should be documented.  

Relapse prevention and preparation for ending

1. Notes should demonstrate that expectations have been clearly set around duration of therapy and preparing for ending.
   
2. Notes should demonstrate that therapist and client have discussed how the client could maintain their progress/wellbeing after therapy ends. This may need to be more or less structured for different clients.
3. Relapse prevention may include discussing coping or self-care strategies the client finds useful, completing a safety or wellbeing plan such as WRAP, signposting or referral to other services.
4. Ending sessions should, where appropriate, document details of any services the client has been signposted or referred to (e.g. if a letter has been sent to the client’s GP with their consent to refer them to NHS services for further support).

Questions?