How to Write Clinical Couples Therapy Notes Using AI
Couples therapists can play a critical role in improving communication between partners. However, their job goes beyond mediating and offering advice to couples in strained relationships. They also ensure that both individuals feel heard and understood.
To this end, therapists must give each person their full attention. However, the dynamics and conflicts can make listening, guiding, and taking notes a challenge.
The good news is that there is AI software to help with taking notes during sessions. Therapists just need to ensure they know how to properly take notes so that they can make the most of their AI software.
What Is Couples Therapy?
Couples therapy is focused on helping partners repair their relationship. Whether they have been dating for several months or have been married for decades, couples therapy is beneficial for improving communication, resolving conflicts, and addressing problems such as finances, health conditions, and intimacy.
What Are Couples Therapy Notes?
As a therapist, you need to take clinical notes during each session. These documents are essential for evaluating goals, providing treatment, and tracking progress for each individual and the couple as a whole. The notes may also include the couple’s history, concerns, interventions, observations, and insights.
Why Couples Therapy Notes Are Important
Couples therapy notes are important because you need to review them throughout treatment. This helps you to track the couple’s progress and adjust their treatment plan as needed.
For instance, your notes may include their goal of improving communication. One technique may involve holding an inanimate object to indicate it is one person’s turn to speak while the other person must listen until the object is passed to them. Use your notes to determine if this technique is working or should be changed.
The notes also serve as a reminder of a specific couple’s purpose for therapy. You may see multiple couples in a day, and the dynamics, concerns, and goals of each couple are a lot for one person to remember on their own. By reviewing their notes, you can use the information to better understand each couple’s needs.
In addition, the notes can be reviewed if the couple needs to refer to a past session or event. The notes can also serve as evidence if the conflict escalates to court.
Finally, couples therapy notes are integral for billing purposes. You may need to present your notes to insurance companies as a requirement for payment or to prove the need for continued service. Many insurance companies will require that certain information be included in the notes, so if you use AI to create your notes, you can be sure that this information is included.
How to Take Effective Couples Therapy Notes
The key to taking clinical notes is to ensure the information is as accurate and detailed as possible. Fortunately, there are several ways to effectively take notes during each therapy session.
You need to pay close attention to each partner to ensure you do not miss any important details or questions. Listening attentively is also necessary for understanding their goals and concerns.
Keep your focus on the facts when taking notes, and leave the judgments, assumptions, and absolutes at the door. Your notes should include facts such as topics discussed, conflicts that occurred, and agreements that were made.
Your notes should also include expressed emotions and notable behaviors during the session. Instead of assuming one partner is disappointed or angry, wait for them to verbally confirm their feelings of disappointment or anger. If the partners begin to raise their voices or nod in agreement, be sure to include those details as well.
Using shorthand makes it easier and more efficient to take accurate notes during longer sessions. Always use industry-accepted abbreviations and acronyms so that if someone else has to use your notes, they understand them.
After each session, review your notes to ensure that all the key details are included and accurate. It is better to read through your notes immediately than to realize you missed important information later. It’s also crucial that you keep up on submitting your notes because Medicare and Medicaid require that notes be submitted within 24 to 48 hours, and each state may have its own separate laws.
Using ICD-10 Medical Codes for Couple’s Therapy Notes
It’s important to use ICD-10 medical codes in your couple’s therapy notes because they represent various diagnoses, including for specific mental health conditions that put a strain on relationships. There is even an ICD-10 medical code for issues with a spouse or partner.
ICD-10 medical codes need to be accurate to ensure your clients are receiving an appropriate diagnosis and treatment. The correct medical codes also provide updated medical terminology, prevent payment errors, and improve overall efficiency.
For instance, a couple’s therapist who realizes one partner may be suffering from anxiety or depression needs to use the correct ICD-10 medical codes when generating their AI notes. This way, they can ensure the client receives the treatment they need from their primary care provider or psychiatrist. Further, the ICD-10 codes can distinguish different types of generalized ailments; for example, generalized anxiety disorder has a different ICD-10 code than social anxiety.
Remember that your notes and use of ICD-10 medical codes must be HIPAA-compliant to ensure your client’s privacy.
Common Sections of Couples Therapy Notes
There are several sections that are usually included in couples therapy notes to ensure you do not miss any vital information.
Functioning Since Previous Session
Tracks the couple’s function since their previous session, such as new problems or changes in the relationship. This section is also used to track the progress made toward the couple’s goals and can help to establish new goals.
Themes and Patterns Identified
Your notes for this section include notable patterns, themes, and issues during the session, such as one partner constantly interrupting or dismissing the other partner’s feelings. These notes should also address the underlying dynamics between both partners.
This section identifies the topics discussed and how they were discussed during the session. It also includes notes on the dynamics and communication style of the couple.
In this section, you are outlining a follow-up plan for future sessions, such as possible techniques based on the topics discussed in today’s session.
For this section, you want to include tasks the couple should complete at home before their next session. These tasks may include journaling, a talking stick, and even a cool-off period when things get heated.
What Techniques Are Used in Couple’s Therapy
When taking notes during a session to generate clinical notes later, you need to ensure that you record all the techniques used in the couple’s therapy. There are multiple approaches to consider for your clients, depending on their needs. Remember to also record how your clients respond to each technique.
The “Talking Stick” method is when an inanimate object, such as a stick, is used to indicate when it is one partner’s turn to speak. The other partner cannot interrupt or talk over the person holding the stick, and they must listen to what their partner is saying. However, the stick is rotated to ensure that both partners have the opportunity to share and listen. The goal is to improve communication by fostering a habit of active listening and being respectful to the person who is speaking.
Reflective listening is another approach to improving communication skills, and this technique can be paired with the “Talking Stick” method or used as a standalone exercise. One part of reflective listening is rephrasing statements with “I” instead of “you” to encourage a more productive conversation. For instance, a partner may rephrase the sentence “You hurt my feelings when you do not listen to me” to “I feel hurt when you do not listen to me.”
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) may be used to help couples identify the strengths and weaknesses of their relationship. This type of therapy focuses on using the strengths as the foundation while working to improve the weaknesses. Whether those weaknesses are problem situations or poor communication skills, couples use CBT to work through the challenges and create a more positive relationship.
Dialectical Behavioral Therapy
Dialectical behavioral therapy (DBT) is when each partner develops mindful awareness of their experience and their partner’s experience at the moment. The goal is to determine what is needed to create a positive change in the relationship.
One example is moving away from judgmental, negative, and invalidating responses to their partner and themselves. Instead, they focus on emotional regulation, healthy self-expression, distress tolerance, and productive communication.
Another part of DBT is learning how to set healthy boundaries using the DEAR MAN exercise, which stands for “describe, express, assert, reinforce, mindful, appear, and negotiate.”
How to Make Writing Couples Therapy Notes Easier
It is not always easy to take couples therapy notes because there are several events happening at once. You need to observe interactions, mediate conversations, propose techniques, and create or adjust treatment plans. Furthermore, you need to recall previous notes, key events, and training methods. This is all done while paying close attention to ensure that your notes are detailed and accurate.
You also need to review your notes to ensure that you did not miss any important information. This is usually done right after the session while the details are fresh in your mind. While guiding a couple to peace is always rewarding, the sessions can be overwhelming as well.
Using HIPAA-compliant AI software, such as AutoNotes, can make it easier to take notes. All you need to do is enter details of the session using prompts, and the software can generate clinical notes.
In addition, some AI software has the ability to listen and transcribe the session, allowing you to give your clients the attention they deserve without missing any key details. Use the software to access a transcription or generate notes after the session. You can even edit the notes to add more details or fit your writing style.
When you use AutoNotes, details, and prompts to generate notes or transcribe the session, you can save both time and stress while providing the service your clients need.