Psycho-Babble Psychology Thread 796041

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What do Ts write about in your file?

Posted by beautymarked on November 19, 2007, at 19:59:12

What's pretty much standard about what they write about you? Are they required to write something after each session? Do they write about specific events you talked about---or is it more diagnostic? I realize it varies a lot...if you all could give me an idea, I'd appreciate it. I kind of wonder what my therapist knew about me before I went into his office.

Thanks :)

 

Re: What do Ts write about in your file?

Posted by beautymarked on November 19, 2007, at 20:48:03

In reply to What do Ts write about in your file?, posted by beautymarked on November 19, 2007, at 19:59:12

oh also, does this include things like interests, hobbies, movies you like?

 

Re: What do Ts write about in your file?

Posted by star008 on November 19, 2007, at 22:45:48

In reply to What do Ts write about in your file?, posted by beautymarked on November 19, 2007, at 19:59:12

did your therapist get info before you went in?? Like was there a previous therapist to get notes from?? I have a pretty good idea of waht they write about since I work in the medical field and have read their notes.
They write about what you are exhibiting when you are there.. Like nervousness, how you express yourself, anything that stands out..Example: like do you constantly move?? What movements do you make?? That is pretty general, I know but that is the basic idea. They also write about important points: like how you grew up, etc. They basically write down everything!! They write down what history they can get from you about your family.
Some will be their diagnostic impressions. Yes, your hobbies will end up there too.. Really, they will have alot of info about you, (if they are good). did I miss something you would like to know?? Ummm they also write down waht you went over in a session so they can follow it to the next session. I once asked my therapist about something that happened ten years ago and he went back and found it. He knows what year I got got divorced and what year I got sober.. I have to ask since I don't write the stuff down..lol..
Anything I missed??

 

Re: What do Ts write about in your file? beautymarked

Posted by Dinah on November 19, 2007, at 22:50:37

In reply to What do Ts write about in your file?, posted by beautymarked on November 19, 2007, at 19:59:12

Depends on the therapist, I think. Some write very detailed notes.

My therapist just rights down something innocuous because he's required to say something. Patient appears anxious. Or patient was distressed about work. Every once in a while he takes an actual note, usually about medication changes, or sleep changes, or something technical like that.

He knows that I, like many I suppose, really don't want our innards recorded and filed.

 

Re: What do Ts write about in your file?

Posted by star008 on November 19, 2007, at 22:55:18

In reply to Re: What do Ts write about in your file? beautymarked, posted by Dinah on November 19, 2007, at 22:50:37

Lots of them write much more than that, you are lucky Dinah. I don't care to have my guts written down but it kind of goes with the territory. I once talked to a therapist with the condition he write nothing down.. He didn't either.. The one I have now writes a whole lot down.. I think most of them do judging by the things I have seen. I don't look at them to be nosey but when they are in a chart in a clinical setting they are sometimes hard to avoid.

 

Re: What do Ts write about in your file? beautymarked

Posted by RealMe on November 19, 2007, at 23:06:07

In reply to What do Ts write about in your file?, posted by beautymarked on November 19, 2007, at 19:59:12

If my T writes anything down, then it is more of a process note, not details. If he does something with my meds, then he would mention that too, I suppose.

I know my T sees people back to back. I am his first of the day at 6:45 a.m. When I leave at 7:30 a.m., his next patient is there. I go use the bathroom in the hallway, and when I come out, he has already taken that person. So, he does not do notes after every session. He has said the details are not what is important to him; it is the relationship and what things are getting in the way. So, does he forget some details, yes. But what he considers important, he does not forget. Like, my trying to entertain him without realizing I was doing this. I did this when I was younger with people too. As soon as I started to talk about an aunt from the past and my acrobats while she talked on the phone, it was like an aha moment. My mother was always depresed and unavailable to me; when I think of her when I was a child, she does not seem real, just a shawdow of a person. Anyway, I guess I tried to get her to laugh as then I knew she cared. Same with T now. These are the things my T remembers, not that I had a bad day at work or that I saw my PCP for something if I happen to mention it. I should ask him if he ever writes notes.

RealMe

 

Re: What do Ts write about in your file? star008

Posted by Dinah on November 19, 2007, at 23:06:30

In reply to Re: What do Ts write about in your file?, posted by star008 on November 19, 2007, at 22:55:18

I don't think I could talk to him if I knew he was writing things down.

Sounds weird, doesn't it, when I spill my guts routinely on an internet bulletin board with the potential audience of any and everyone.

But at least these are my own words. I find that when someone else writes down what I'm saying, it's not really what I said at all. Not even if they quote. Because they're taking the quote out of context, even if they write it word for word. Whenever I've read my notes, I usually get upset.

Even with my therapist really. He doesn't say much at all, and nothing of substance. But I still don't like how he says it. (Every once in a while I ask him what he wrote and he'll read it. Like if he write something at an unusual time.)

 

Re: What do Ts write about in your file?

Posted by obsidian on November 19, 2007, at 23:11:12

In reply to Re: What do Ts write about in your file? star008, posted by Dinah on November 19, 2007, at 23:06:30

"obsidian is tearful, labile....I can no longer work with this exasperating, intractable patient, yadda yadda yadda"

or something like that...
just kidding

 

Re: What do Ts write about in your file? obsidian

Posted by star008 on November 19, 2007, at 23:23:20

In reply to Re: What do Ts write about in your file?, posted by obsidian on November 19, 2007, at 23:11:12

I hate the notes too.. Really hate them but I have been in therapy so long that I no longer care if it is on paper.. I do hate it when he reads something I said though and I don't like it at all when he starts talking about what we talked about that last time I was there either.. He didn't used to take notes when I was around but the notes were there anyway.. He listened and then wrote the stuff down later. No, I don't like it but it is reality.. They can't remember everything you ever told them without looking it up..

 

Re: What do Ts write about in your file?

Posted by star008 on November 19, 2007, at 23:24:19

In reply to Re: What do Ts write about in your file? obsidian, posted by star008 on November 19, 2007, at 23:23:20

sorry that note was for everyone

 

Re: What do Ts write about in your file?

Posted by Dinah on November 19, 2007, at 23:34:14

In reply to Re: What do Ts write about in your file? obsidian, posted by star008 on November 19, 2007, at 23:23:20

Is it awful to admit that I *like* that my therapist forgets what I've told him? Maybe at first it was annoying, but after all this time together it's a pretty handy trait. I can tell him something and it's like it's totally new and interesting to him. And I can compare his response to the last time I told him.

I also preface any remarks I make building on a previous session with a brief recap of that session so that he can either refresh his memory or fake it. I don't inquire too closely.

 

Re: What do Ts write about in your file?

Posted by star008 on November 19, 2007, at 23:43:10

In reply to Re: What do Ts write about in your file?, posted by Dinah on November 19, 2007, at 23:34:14

Dinah,

I know you weren't meaning to be funny but you made me laugh.. I have done the same thing.. Tell them something twice and it is interesting and then and watch the reaction the second time..Sometimes it was so much different too..lol other times there were things I said that I didn't want to talk about again and the forgetting was helpful..Doesn't happen much for me anymore.. The notes help him out..d

 

Re: What do Ts write about in your file? star008

Posted by Dinah on November 19, 2007, at 23:47:12

In reply to Re: What do Ts write about in your file?, posted by star008 on November 19, 2007, at 23:43:10

Welll..... I didn't mean to be *not* funny. :)

 

Re: What do Ts write about in your file?

Posted by star008 on November 20, 2007, at 0:13:54

In reply to Re: What do Ts write about in your file? star008, posted by Dinah on November 19, 2007, at 23:47:12

One time my T forgot something really important that had a major affect on my life.. It was a really huge terrible thing. To him it was new info
and he was all concerned about it.. I told him that I told him about it years ago and he went and looked back and saw that I had. I understand the limits of a therapeutic relationship but this was so big that i was hurt that he forgot. I think maybe he didn't believe me when I told him about it the first time and let it go?? It was sexual abuse by someone that he wsn't directly involved with but was familiar with.. how could he forget that one??

 

Re: What do Ts write about in your file? star008

Posted by Dinah on November 20, 2007, at 0:26:57

In reply to Re: What do Ts write about in your file?, posted by star008 on November 20, 2007, at 0:13:54

It isn't at all funny when that happens. I think things like that might have happened closer to the beginning of our therapy. And it did hurt.

There is something that I told him exactly once and never intend to tell him again, and sometimes he seems like he has forgotten it. And I'll get upset and say that if he didn't remember it, then good, I certainly won't tell him again. And he says he does remember. I guess I'll never know because I'll never ask him what it is he thinks I'm talking about, or let him talk about it.

I'm sorry if my answer sounded flippant. It wasn't meant that way, and it bothered me as soon as I hit submit.

All I meant was that I rarely intend to be funny. I never set out to make people laugh, and I doubt I could if I tried. But sometimes, like this time, I find humor in my thoughts or actions, or in the human condition, and I'm always open to sharing my amusement with others and am happy to do so. Just as when I'm feeling playful I tend to enjoy sharing that with others, and am happy when I succeed.

I didn't mean to make light of the topic, or minimize the possible pain it can bring.

I was just remembering fondly some exchanges with my therapist.

 

Re: What do Ts write about in your file?

Posted by star008 on November 20, 2007, at 1:04:23

In reply to Re: What do Ts write about in your file? star008, posted by Dinah on November 20, 2007, at 0:26:57

beauty..

probably way more than you asked for. hope we were able to help you anyway.. please let me know if you have more questions

 

Re: What do Ts write about in your file?

Posted by beautymarked on November 20, 2007, at 1:18:10

In reply to Re: What do Ts write about in your file?, posted by star008 on November 20, 2007, at 1:04:23

Yeah, you guys helped :)

Nothing really surprised me. I just wanted to know HOW detailed--like if they would write about, say, a movie you casually bring up and relate to but may have no significance about your treatment. Or intellectual beliefs. It's really impossible for them to write down every detail though. The reason I asked WAS because my therapist read over my previous therapist's notes, so I was wondering how much information he would've known.

Thanks everyone. If you have anything more to contribute, please do :)
> beauty..
>
> probably way more than you asked for. hope we were able to help you anyway.. please let me know if you have more questions

 

Re: What do Ts write about in your file?

Posted by star008 on November 20, 2007, at 2:26:11

In reply to Re: What do Ts write about in your file?, posted by beautymarked on November 20, 2007, at 1:18:10

beauty.
I think it has to do with the therapist about how detailed things are.. mine would remember the movie..lol In themedical field if there is no documentation then nothing was done.You have to document in case anyone comes back to check you out with insurance or lawsuits. I would like toask my T how long he will keep those records and if he can dispose of the older ones. My life on paper..I don't know that I care thatmuch but would rather dispose of the pain than have it forever written on paper..sorry if it got way off track beauty.. I think u should just ask. Must feel strange not knowing how much someone knows about you and trying to talk to them.. I can see why you asked
hugs

 

Re: What do Ts write about in your file? star008

Posted by Phillipa on November 20, 2007, at 11:50:59

In reply to Re: What do Ts write about in your file?, posted by star008 on November 20, 2007, at 2:26:11

Don't some dictate notes and then transcribe later? I know my pdoc does a quick checklist is all and then writes the prescriptions for documentation. Phillipa

 

Re: What do Ts write about in your file? beautymarked

Posted by Muffled on November 21, 2007, at 22:05:17

In reply to What do Ts write about in your file?, posted by beautymarked on November 19, 2007, at 19:59:12

My T writes very little.
I think for legal reasons they keep it to a minimum perhaps.
Also, not enuf time for copious notes!
My T has seemingly forgotten stuff, or MANY times 'not gotten' stuff I thot I was very clear about previously...
I communicate mostly by writing.
Maybe thats why?
Anyhow, its taken a long time, but I finally feel she 'gets' me more often, and 'knows' me much better, and as a result sometimes even anticipates stuff.
I dunno, the whole T relationship thing is SO freaking confusing at best....
Good luck w/therapy!
Can you ask to see the previous T's notes? Or ask what they said?
I have occasionally asked bout reports etc, it was VERY hard to do, and VERY hard to hear somehow though...
Take care, pleased to meet you.
Muffled

 

Re: What do Ts write about in your file?

Posted by star008 on November 22, 2007, at 7:10:39

In reply to Re: What do Ts write about in your file? star008, posted by Phillipa on November 20, 2007, at 11:50:59

Yes I think alot of them just take short notes and dictate later.. Alot of clients don't like the T writing things down while they are talking to them. I am sure some are more detailed than others. The ones I have seen are detailed enough for you to figure out what is going on..Because of my job I have seen more than a few of their notes. I try not to read them at all if there is not info there I need.

 

Re: What do Ts write about in your file?

Posted by antigua3 on November 23, 2007, at 6:47:58

In reply to What do Ts write about in your file?, posted by beautymarked on November 19, 2007, at 19:59:12

My T never takes notes, unless it's to remind her about something (maybe something we agreed to talk about next time), and that's usually on a scrap of paper on her messy desk. She says she never keeps notes, at least with people like me, to protect us both. She has an absolutely excellent memory. What I like is that her note taking doesn't detract from our session.

My pdoc, on the other hand, takes copious notes, all the time, to the point of not being fully involved with the session. I would never want to read what he writes! Since I think he misinterprets me so much, I would hate him for what he writes. I'm always asking him, "What are you doing?" when it looks like he's writing something major. It's something to discuss; I've already told him that all his electronic gadgets bother me--he writes everything into his fancy computer, and as I said, I never want to know what he writes. It's something for us to work on.
antigua

 

I asked my T about this today, and read some notes

Posted by Racer on November 23, 2007, at 23:58:47

In reply to Re: What do Ts write about in your file?, posted by antigua3 on November 23, 2007, at 6:47:58

Today, I told my T about this thread, and asked her about her notes. We talked about it a little, and then she showed me a page of notes from a few weeks ago.

She said that, way back when she first started her practice, she took too many notes -- and learned that when her records were subpoenaed for a custody case. Now she takes much shorter notes as a result. Her memory is notoriously bad, it's a joke with her clients at this point, and she never takes notes during sessions, so I don't expect her to remember most details of what we talk about. She remembers the oddest things, sometimes, and that can be inconvenient. (Of course, she also remembers quite salient things -- she mentioned the other day that she remembered me saying that if I couldn't get pregnant, at least I could work on losing some of the weight I've gained. She brought that up the other day, after asking how much I was eating -- a subject we actually never talk about.) After talking about them a little, she handed over a page of notes from a couple of weeks ago, right before and during my hospitalization. There were several days worth of notes, handwritten, and had various brief comments. I wish now I'd asked to see some notes that weren't from that period, to see what "normal" notes looked like, but at least I have a pretty good idea now of what's in my file.

The other thing that would help would be legible handwriting...

It helps that I trust her. Way back, we talked about it, and I said that I probably would want to read my whole file at some point. She said that we would talk about it, and that she'd want to do it in session, but that if I really wanted to, we would do that. I found that reassuring.

 

Re: I asked my T about this today, and read some n

Posted by beautymarked on November 26, 2007, at 22:11:14

In reply to I asked my T about this today, and read some notes, posted by Racer on November 23, 2007, at 23:58:47

Hi Racer,

I'm glad that you satiated your curiosity. I guess the only way to do it is to ask your T directly huh :) Can I ask if what your T wrote were like interpretations or just brief facts about what you experienced and what you felt?

> Today, I told my T about this thread, and asked her about her notes. We talked about it a little, and then she showed me a page of notes from a few weeks ago.
>
> She said that, way back when she first started her practice, she took too many notes -- and learned that when her records were subpoenaed for a custody case. Now she takes much shorter notes as a result. Her memory is notoriously bad, it's a joke with her clients at this point, and she never takes notes during sessions, so I don't expect her to remember most details of what we talk about. She remembers the oddest things, sometimes, and that can be inconvenient. (Of course, she also remembers quite salient things -- she mentioned the other day that she remembered me saying that if I couldn't get pregnant, at least I could work on losing some of the weight I've gained. She brought that up the other day, after asking how much I was eating -- a subject we actually never talk about.) After talking about them a little, she handed over a page of notes from a couple of weeks ago, right before and during my hospitalization. There were several days worth of notes, handwritten, and had various brief comments. I wish now I'd asked to see some notes that weren't from that period, to see what "normal" notes looked like, but at least I have a pretty good idea now of what's in my file.
>
> The other thing that would help would be legible handwriting...
>
> It helps that I trust her. Way back, we talked about it, and I said that I probably would want to read my whole file at some point. She said that we would talk about it, and that she'd want to do it in session, but that if I really wanted to, we would do that. I found that reassuring.
>
>

 

Re: What do Ts write about in your file? Phillipa

Posted by lovelorn on November 27, 2007, at 10:39:14

In reply to Re: What do Ts write about in your file? star008, posted by Phillipa on November 20, 2007, at 11:50:59

Interesting question and replies. My therapist doesn't take notes while we are speaking. I am going to ask her if she writes some afterwards. Either way, she is good in remembering what we've said from session to session. I see her tomorrow and will ask her what she writes, if anything.


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