Tools of the Trade: Soft ware for Counselors
of experience to reproduce. The software system is a powerful addition to deepen and document treatment plans yet will not be a match for all clinicians. It certainly has significant educational potential for new counselors.
Getting the myriad details of counseling plans, interactions, risk factors, and progress notes into a treatment record can become a burdensome duty and increase burnout unless the counselor has a good system for record keeping. There is no compelling reason to move to a client management software system if the paper/pencil or basic word processing format is getting the job done. Software systems designed for counselors do offer advantages because built-in prompts structure progress notes or allow for the quick insertion of checklists. Some of these procedures could be incorporated into more basic formats. Consider the use of a template for a standard mental status exam, which could be included as a file in a word processor or just printed out as a handy form ready to be completed.8 Having this ready to use or insert can save time and make the difference in documenting such observations at regular
intervals. Following is an example of an integrated client management software system that can be a huge help in maintaining an up-to-date clinical record.
Option by The Psychological Corporation is a sophisticated program with some high-level features, and therefore, it barely squeezes past the barbershop criteria. The setup and start-up commitment cannot be fairly described as ‘simple, since this is actually a subscription service that requires a monthly connection to update the software along with the built-in assessment features. It does have several standard assessment measures built right into the program. Once it is up and running, a steep learning curve must be factored in because it will take some work to gain familiarity with what options are available. The format itself is easy to follow, with the
inclusion of many templates and drop-down menus such as those for intake assessment, social history information and treatment plan generation. One attractive feature is the way it assists in formulating progress notes and goal tracking. The options for rating goal-level attainment after each session, with the potential to pull ratings over time into a graphic presentation of progress, is the type of outcome assessment feature that will become common practice in the not too distant future. Once the clinician becomes acquainted with this system, the features it offers fit well with routine practice.
*Sleeping Soundly*
In my early counseling days, some of the most dreaded phone messages were not client crisis calls but requests for information or billing records. A client who finished therapy eight months earlier phoned and wanted a complete, itemized account statement for tax preparation purposes. The information was obtainable but going through the receipts took time. Phone disputes surfaced with insurance companies over explanation of benefit (EOB) notices, which required going back?
through dates of service and payment records. A request came from a fellow counselor beginning work out of the area with a previous client and who expected a written summary of treatment. These common tasks needed to be transformed from major inconveniences to matters of doing everyday business. Hiring staff helped, but only limited hours could be afforded. Also, even office staff need good recording systems to manage information. This is where practice management database software is extremely useful.9 An example of such a system is The Practice Manager with Shrink from Multi-health Systems (MHS). This program has features for tracking clients, recording progress notes, billing management, accounts receivable, and producing insurance forms. It has built in DSM-IV and clinical procedure terminology (CPT) codes.
There are safeguards to protect confidential information and passwords to restrict access. Having all the typically requested information at ones fingertips in a central database is not just a dream come true, but it also allows for pleasant dreams instead of nightmares. It cuts out unnecessary worry about who is going to want what and when. The information available can be recalled when necessary. The use of such a system must work naturally into clinical routines. This might mean posting payments/ charges at the time of service, doing progress notes throughout the day, and closing client records with a summary of care. There are times when catch-up is required at the close of the day or at weekly times designated for clean up, but most information management is
seamlessly integrated into clinical practice. Having this done allows for more restful sleep. Another word from experience: Adoption of a practice management software system is a decision one will live with for
a long time, since conversion to a