How to Write Play Therapy Progress Notes
Cathi Spooner 
Today, I want to share some tips on writing play therapy progress notes. If you're a play therapist, you've probably struggled with this at some point. It can be challenging to capture the essence of what happens in a session without making it seem like it's all just fun and games. Here’s how to make your notes meaningful, professional, and therapeutic.
Why Writing Progress Notes is Challenging
Progress notes can be a source of frustration for many mental health professionals. Often, we don't get much training on how to write cohesive notes that meet various expectations. And let's face it, attending training sessions on documentation isn't usually at the top of our to-do lists. But despite their lack of glamour, well-written progress notes are crucial.
Common Concerns and Misconceptions
One common fear is that our notes will be scrutinized, leading to negative consequences if they don't meet standards. This can be especially true in settings where third-party payers, like insurance companies, are involved. Therefore, learning to write effective progress notes is an essential skill for any therapist.
Tips for Writing Effective Progress Notes
1. Use a Framework
Using a framework like SOAP, DAP, or BIRP can help organize your notes effectively:
- SOAP: Subjective, Objective, Assessment, Plan
- DAP: Data, Assessment, Plan
- BIRP: Behavior, Intervention, Response, Plan
Each of these frameworks helps structure the information from the session, making it easier to capture what's important.
2. Think of Your Notes as a Story
Imagine your progress notes as your client's hero's journey. Each session is a chapter in their healing process. This approach helps you document the therapeutic journey in a way that's engaging and easy to follow.
- Identify Themes: Look for recurring themes in your client’s play. These themes can provide valuable insights and should be noted in your assessment section.
- Chapter Structure: Each session (or stage of therapy) is a chapter in the story. Document the beginning, middle, and end phases of treatment to show progress over time.
3. Understand the Language of Play
Play is the language of children. Your play therapy theoretical model is the framework that helps you interpret this language. Use the terminology and concepts from your model to describe what’s happening in sessions. This not only makes your notes more professional but also ensures they’re grounded in therapeutic principles.
4. Maintain Balance
While it’s important to be thorough, avoid writing too much or too little. Provide enough detail to capture the essence of the session without overwhelming the reader. Your framework will help you strike this balance.
By following these tips and approaches, you'll be well on your way to writing effective, professional, and therapeutic progress notes.
If you're interested in a deeper dive into writing effective play therapy progress notes, check out my new online, self-paced course, "Getting Grounded in Play Therapy Progress Notes." This course walks you through various frameworks, provides case studies, and offers tips on writing notes quickly and ethically.
Categories: : Play Therapy, Podcast, Progress Notes
