Take Note
Unless you have a super human memory, you probably take notes of your client sessions.
Among other things, you need to remember who they are, what they want to work on and what progress they are making. Most practitioners do this by taking notes, but what do you take notes of, and what do you do with them when you have taken them?
If you have come to tapping from a profession where note-taking was required as part of your role, you already know how to do this. However, if you have come into tapping from another profession (as I did) you may not be familiar with professional note-taking.
There are many flavours of tapping practitioner, including licensed therapists, healers, coaches, educators etc., they all need different kinds of notes depending on their role and circumstances. Therefore, this article can only discuss note-taking in general terms.
Why take notes in the first place?
There are several different reasons to take notes:
Continuity of care
Notes are a way of recording your client’s progress and the themes you are working on. By knowing where you have been, and what you have been working on, you can gauge progress, move on to new issues as old issues are resolved.
Legal reasons
You may be required to keep notes for legal reasons, such as:
- If you are licensed / certified in some way, your regulatory body may require you to keep notes of your sessions.
- Your insurance company will want you to keep your notes for a period of time in the event of a legal case against you (my insurance company requires me to keep my notes for 6 years after my last session with a client).
- If you work with particular groups of people, such as children or vulnerable adults you may have extra legal requirements as part of your work.
Whatever your reasons for taking notes, the notes themselves may fall under data protection legislation such as the GDPR in Europe and the UK.
Accountability
If a complaint or legal proceeding is brought against you, written records of your session may support you as you go through that process.
Mentoring / Supervision
If you are receiving mentoring or supervision (and you should be), having notes of your client sessions will help you bring the details of your work into the mentoring session so you can get the most out of your discussions.
It can be helpful to keep your notes from your mentoring sessions as they can demonstrate that you sought help from you mentor if your work comes under scrutiny.
In summary, your notes demonstrate your care, competence and professionalism in a physical form, and if they are well-kept, they will help you develop your skills in good times and help support in bad times.
What should go in your notes?
Before you start taking notes, it is worth remembering that your notes may become a part of a legal or disciplinary process, therefore:
- before you start, you need to know the legal and insurance requirements of your jurisdiction.
- the notes you keep need to be factual and ‘objective’.
- in the event of a complaint against you, or any involvement in a legal proceeding, you have to be able to stand by them and justify what you wrote.
- depending on the data protection rules you live under, you may be required to disclose your notes to your client. (If this is the case, it’s worth asking yourself, “Would I be comfortable if my client read my notes?”)
For example, if you have written in your notes that you think your client has ‘borderline personality disorder’ when you have no training, or authority to diagnose them, these speculations may cause you trouble.
As an additional complication, if you practice other modalities, then you may need to reconcile your tapping notes with what is expected of you from your other governing bodies.
Types of notes
Notes can be broken down into three broad categories:
1. Progress notes
Progress notes contain information about the client and the work you are doing together.
These notes include the information that is required by the law, your insurance company and your professional body (these notes may include a diagnosis if you are qualified to give one).
In general, these notes will include the client’s address and contact details, an emergency contact number if the client becomes unwell in a session, and you cannot assist them in person (for example if you are working online).
If you are in the UK, it is advisable to have the contact details of the client’s GP in order to contact in the event of serious mental health concerns.
Some of this might seem overcautious, and I have never personally needed to use the emergency contact number, or GP’s contact details in 20 years of client work. However, like a parachute, it’s much better to have one that you don’t use, than to need one that you don’t have.
After the contact information your notes should include the goals and outcomes expressed to you by the client, and a description of the presenting problems and issues that brought them to you.
As sessions progress, these notes can describe the progress the client is making towards their goals.
Process Notes
Process notes are a description of what you did with the client.
These are notes about what occurred during the session, the themes explored, the approaches and techniques you used and the responses that the client gave.
They also note where you left off at the end of one session so that you can revisit it at the start of the next one.
Action Notes
These are notes that you make about actions you may need to take, perhaps with others, as a result of what you have learned from your client.
Any actions you need to take to comply with the law, take care of the client’s safety, or to address a safeguarding issue must be carefully recorded.
For example:
- If your client tells you that their child is being sexually abused by another family member, you have a moral, and probably legal, obligation to do something about that.
- If your client tells you that their partner is threatening their life, you must act to help protect your client.
What you do, and how you do it, in such circumstances will be governed by your local laws and practices. However, what you do, and why you do it, needs to be carefully recorded in your notes so that you can explain and stand by your actions in any legal processes or disciplinary proceedings that follow.
It is oft said “If it isn’t written down it didn’t happen”, writing down the necessary actions you take is an important defence for you if it is ever required.
Note: whatever kind of notes you are making, remember to date them.
What shouldn’t go in your notes?
Your notes should be factual and ‘objective’ (to the degree that is possible) they should not contain speculation or diagnoses you are not authorised to make, which you may later have to justify making.
How do you keep your notes
If you handwrite your notes, they need to be kept in a secure, locked location (usually a filing cabinet).
If you keep your notes on your computer, they should be encrypted so they cannot be accessed by any other person.
If you keep your notes in the cloud, they should be encrypted before being uploaded and stored in a secure location. (In a recent case in Finland, a hacker accessed therapist records from an online service and leaked them to the public! )
After the appropriate span of time, your paper / online notes should be securely deleted.
I hope this brief overview has been helpful, if you have any specific questions contact your mentor for their advice.
Image by tookapic from Pixabay
Every month I send out an email newsletter for tapping practitioners, in it I explain strategies and tactics to work with some of the challenges that typically face tapping practitioners.
As a bonus, when you sign up you will get access to my 30 minute video explaining my intake process in detail (a good intake process can make a practitioner’s life a lot easier). I will also give you access to a half-priced copy of my 300 page paperback book ‘The Tapping Toolkit’.