Tips for Staying on Top of Documentation

Keeping up with documentation can be one the most time-consuming aspects of being a therapist. Between session notes, treatment plans, and administrative paperwork, it can be easy to fall behind. However, staying on top of documentation doesn’t have to feel like an endless task. With the right strategies, you can keep your notes up to date while maintaining focus on what matters most — your clients.

Here are some practical ways to streamline your documentation process and make it more manageable.

1. Don’t Take Notes During Sessions — Capture Them Right After Instead

It can be tempting to jot down notes while your client is talking, but that often pulls you out of the moment. Instead, focus on being present during the session and make time for notes right after.

Try this:

✔ Stay present: Eye contact and body language matter. Trust that you’ll remember the important details.
✔ Use a quick recall method: Right after the session, write down key takeaways while they’re still fresh — even just 5 minutes can be enough.
✔ Avoid the “halfway note” trap: Taking partial notes during a session with the intention of finishing them later might seem efficient — but it often leads to procrastination. You’ve started the note, so your brain checks it off the list… but then it lingers, incomplete. Completing your full note right after the session keeps the momentum going and ensures the details are accurate while still top of mind. 

This method helps you stay client-centered in the room, avoid procrastination, and keep your documentation timely and efficient.

2. Schedule Dedicated Time for Notes

Rather than squeezing in documentation at the end of a long day, set aside specific time blocks in your schedule for note-writing.

✔ Use the Pomodoro Method and work in focused 25-minute intervals with short breaks to stay efficient and avoid burnout.
✔ Block out time right after each session to complete notes while the details are fresh.
✔ Dedicate one or two specific time slots per day to catch up on documentation.

When documentation becomes part of your routine, it’s less likely to pile up.

3. Use a Structured Note-Taking Format

A clear, structured format can speed up the note-writing process and ensure consistency.

✔ Use Note Templates: Great Lakes Psychology Group’s EHR system includes built-in progress note templates, making documentation more efficient and standardized.
✔ Stay Consistent: Following a structured approach reduces decision fatigue and keeps your notes organized.
✔ Simplify Your Process: Pre-formatted templates help streamline your workflow, so you can focus more on client care and less on paperwork.

Using a structured system ensures your documentation is thorough while saving you time.

4. Set Clear Boundaries with Yourself

If you tend to bring work home, documentation can start to take over your evenings and weekends. To prevent this:

✔ Establish a cut-off time for writing notes each day.
✔ Resist the urge to go back and over-edit your notes unnecessarily.
✔ Keep in mind that documentation is a tool for client care, not an academic paper — it just needs to be accurate and sufficient.

Sticking to clear boundaries helps you maintain a healthy work-life balance while staying on top of your tasks.

5. Leverage Technology to Your Advantage

If you’re still relying on paper notes or an outdated system, consider upgrading to a more efficient digital solution.

✔ Set up auto-reminders for unfinished notes.
✔ Utilize secure storage for client documentation to stay organized.
✔ Use an EHR system with integrated note-taking features.

Great Lakes Psychology Group offers an EHR system with built-in note templates and secure storage, making it easier to keep up with documentation while maintaining compliance.

Make Documentation Work for You

Rather than letting paperwork pile up, implementing simple strategies can help you stay ahead of your documentation without stress. By being fully present in sessions, scheduling dedicated note-writing time, and using structured formats, you can make documentation an easier and more efficient part of your practice.

Looking for tools to simplify your workflow? Great Lakes Psychology Group provides administrative support and EHR solutions to help you focus on what truly matters — your clients. Learn more at careers.glpg.net.