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DRAFT — Charting standards (Associate Handbook)

Purpose

Set a consistent minimum standard for session documentation in JaneApp.

Timing

  • Notes must be entered in JaneApp for all sessions completed.
  • Deadline: within 48 hours.

Minimum content

The current standard in BC (as advised by the BC Association of Clinical Counsellors — BCACC, and aligned with other Canadian counselling/psychotherapy bodies like CCPA and common risk-management guidance) emphasizes clear, objective, respectful, clinical documentation. This includes:

  • descriptive, behavior-based wording, not interpretation or inference
  • use of client’s words where possible
  • avoiding conjecture, assumptions, judgments, or labels
  • documenting observable behavior or report, not internal states unless directly stated by the client
  • documenting therapist intent, interventions, and rationale
  • avoiding pejorative or vague phrasing

Over time this has moved away from older, more hierarchical formats (e.g., “client denies…” or “client is…” with therapist inference) toward trauma-informed, relationally respectful documentation.

📌 Core Principles for Charting Notes (BCACC / ethical best practice)

1. Objectivity

Record what is observed or directly reported, not what you think it means.

Good: “Client reports feeling overwhelmed and tearful when discussing recent stressors.”

Avoid: “Client is overly emotional and unstable.”

2. Use Client’s Words Where Possible

This both calibrates accuracy and protects clinical integrity.

Example: “Client stated, ‘I don’t know how to handle this anymore’.”

This is preferable to paraphrasing into therapist interpretation unless clearly stated.

3. Avoid Labels, Diagnoses, and Personality Judgments Unless Clinically Appropriate

Counselling notes should describe, not label someone’s character or motives.

Not recommended: “Client is manipulative.” “Client is resistant.”

Better: “Client declined to engage in the exercise today and reported feeling mistrustful of the intervention.”

4. Therapist Observations Should Be Described

But they should be clearly distinguished as observation, not clinical inference.

Example: “Client avoided eye contact, shoulders tense and breath shallow.”

Not: “Client is defensive.”

5. Interventions and Rationale Should Be Documented

Including why an intervention was chosen, not just what was done.

Example: “Introduced grounding technique to assist client in down-regulating after intense affect. Client practiced with moderate facilitation.”

6. Progress and Planning

Notes should include outcomes and next steps.

Example: “Client completed three of four agreed-upon coping strategies this week and reported modest relief. Next session will focus on expanding behavioral activation skills.”

When clinically relevant, please also note whether you are:

  • recommending further therapy (e.g., ongoing sessions, a defined number of sessions, or a check-in plan), and/or
  • referring the client to another counsellor (internal or external), including what was discussed and the agreed next step.

If you are referring the client to another counsellor within Head & Heart, please follow the internal referral/transfer procedure:

📌 Current Recommended Note Formats

Many clinicians use structured frameworks — not because any single one is mandated, but because they support clarity, objectivity, and defensibility.

Below are three formats widely used in BC clinical settings (including BCACC contexts):

✅ 1. Descriptive Note (Narrative)

Focuses on clear narrative with objective language.

Example:

  • Session Focus: Reviewed impact of workplace stress on sleep.
  • Client Report: “I fall asleep but wake up at 2 a.m. and can’t get back to sleep.”
  • Observed Affect/Behavior: Client appeared fatigued, slow speech, frequent sighs.
  • Interventions: Reviewed sleep hygiene; introduced breath meditation for nighttime arousal; role-played self-soothing instructions.
  • Client Response: Client engaged with technique and practiced with therapist support; reported slight decrease in anxiety during role-play.
  • Plan: Client to practice nightly breathing exercise and track sleep pattern; follow-up next session.

No opinions about character; no diagnostic statements unless clinically justified and contextualized.

✅ 2. BIRP (Behavior, Intervention, Response, Plan)

A common structured approach that stays descriptive.

Example:

  • B: Client reported frustration at work and difficulty sleeping; tears at times.
  • I: Reviewed distraction reduction strategies; practiced grounding exercise.
  • R: Client accepted techniques; reported they felt “somewhat helpful.”
  • P: Continue grounding nightly; schedule check-in on mood mid-week.

✅ 3. SOAP (Subjective, Objective, Assessment, Plan)

Often used but with caution to keep “Assessment” clinical and observable rather than interpretive.

Example:

  • S (Subjective): Client reports having “lost motivation” over past two weeks.
  • O (Objective): Observed minimally engaged posture; slowed rate of speech; consistent with self-reported fatigue.
  • A (Assessment): Clinical formulation: Impact of situational stress and sleep disruption on mood stability; no evidence of imminent risk (per risk assessment today).
  • P (Plan): Review sleep hygiene techniques; regular mood monitoring; consider referral to psychiatry for possible sleep trial.

Note: In the Assessment section, phrasing must be formulations tied to observable data or client report, not evaluative judgments about personality or “willpower.”

Risk and Safety Documentation

When documenting risk, please be specific and descriptive:

Avoid: “Client is suicidal.”

Better: “Client endorsed thoughts of self-harm without plan or intent; no access to means; protective factors identified.”

And please always note:

  • what was asked
  • what was said
  • any risk formulation
  • what actions were taken
  • safety planning and follow-up

📌 Therapist Language: “I” vs “the client”

Best practice is to avoid both overly passive and overly authoritative language.

Avoid:

  • “Client reports…” without context
  • “The therapist believes…”
  • “The client is…”

Prefer:

  • Client stated…
  • Client reported…
  • Client described…
  • Client appeared…
  • Observed…
  • Client endorsed…
  • Risk assessment conducted with findings…

This keeps notes neutral and traceable.

📌 What BCACC Cautions Against

The BCACC Code of Ethical Conduct advises against:

  • pejorative language
  • vague labeling (“resistant client,” “unmotivated,” etc.)
  • assumptions about internal states not reported by client
  • judgments about character or intent
  • notes that could be interpreted as punitive or moralistic

Rather, clinicians should document in ways that:

  • preserve dignity
  • are trauma-aware
  • support continuity of care
  • are useful for treatment planning
  • are defensible if reviewed by third parties (supervisor, legal, insurance)

🧠 A Practical Clinician Checklist for Note Writing

Before signing a note, ask:

  • ✔ Does this describe behavior or client report?
  • ✔ Am I avoiding interpretation and judgment?
  • ✔ Can someone reading this later understand what happened?
  • ✔ Have I documented therapist interventions and rationale?
  • ✔ Have I noted risk assessment and planning if relevant?
  • ✔ If relevant, have I documented recommendations for further therapy and/or a referral plan?
  • ✔ Would I be comfortable sharing this with the client?

If yes, the note is on the right track.

Addendums / corrections

If you need to correct or add to a note after it has been entered:

  • Please add a dated addendum (do not overwrite the original note where possible).
  • Please state what you are correcting/adding and why (briefly, objectively).

If you’re behind

  • Contact admin/Katherine early and make a catch-up plan.

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