Progress notes are a vital aspect of any counselor’s work, and career counselors are no exception. The career counseling process builds upon itself, and it is important to see a client progressing. Client attendance can also be sporadic, so having a solid record of all counseling sessions helps career counselors better serve their clients. Additionally, even though career counselors do not directly address mental health issues, it is important to assess if a client needs to seek supplementary assistance for personal concerns. Take the following fictional case study as an example:
Ariana is a 26 year old undergraduate student in her junior year. She took time off from school when her mother was diagnosed with lymphoma. Her mother passed away two months ago, and Ariana’s father has “forced” Ariana to return to college to earn her degree, especially since there are three younger siblings at home. Ariana’s father needs her to get good grades and major in “something worthwhile” so that she can help support the family financially. Ariana originally wanted to major in history with the goal of becoming a history professor, but now she is changing her major to business administration. She is seeking career counseling to find out about the types of jobs she can get and what she should do to “make the most” of the next two years of college. When she meets with you, a career counselor at her university, Ariana appears unkempt in baggy sweatpants, an oversized t-shirt and uncombed hair. She barely looks you in the eye, shifts around in her chair a lot, and seems tearful when she briefly refers to the loss of her mother. Ariana shares that she is having a hard time concentrating in her business classes and does not sleep much given that she is working a full-time job to help pay for college.
The STEPnotesTM method provides concrete “STEPs” for documenting this session:
“S” refers to the SUBJECTS the client discussed and the SYMPTOMS the client reported or exhibited. Subjects Ariana disclosed include: death of her mother, change of major, and stress. Symptoms can be emotional, behavioral, cognitive, and/or physical. Ariana’s emotional symptoms appear to be sadness and uncertainty. Behavioral symptoms to document for Ariana include loss of sleep, minimal eye contact, acting withdrawn, and agitation. Ariana’s difficulty concentrating is a cognitive symptom, and her disheveled appearance is a physical symptom. Seeing how the subjects and symptoms increase, decrease or change over the course of counseling help the career counselor better ascertain ways in which career counseling is progressing.
“T” refers to the actual THERAPEUTIC TOOLS the counselor utilized during the session with the client. For example, Ariana’s career counselor may utilize Holland’s theory of vocational choice or Super’s developmental self-concept theory. Also, the counselor may be person-centered or use solution-focused techniques with Ariana. In addition to the therapeutic approach, what the counselor actually does during the session should be documented in the progress notes by using action verbs. Words such as, “aligned, demonstrated, explored, reframed” are all examples of action verbs that can start a sentence describing how the counselor put a theoretical approach into practice. For example, “Explored Ariana’s reason for changing majors and what she hopes to accomplish by doing so.”
“E” indicates the EVALUATION section of the progress note. Evaluation involves the client’s level of engagement in therapy; for example, is the client minimizing, open, or guarded? In the example with Ariana, it appears she is somewhat guarded. Evaluation also needs to include an assessment of the client’s current level of functioning. Utilizing a scale of 1 to 10 is helpful, with “1” indicating an inability on the part of the client to engage in career counseling and a “10” signifying that the client has met her career counseling goals. Ariana is probably functioning at a “2” to “3” level given that she is dealing with the loss of her mother, pressures from her father, and uncertainty about her major. In this section, it would also be important for the career counselor to note if the client was referred to additional services to deal with deeper concerns, such as grief over the loss of a parent.
“P” is the last part of the progress note and references both the short- and long-term PLAN for the client. The plan may include the homework, assessments, and long-range goals. Examples of a plan for Ariana may include taking a career assessment of her interests and skills, exploring jobs one can get with a business major, and learning about resources to deal with the loss of her mother. The plan can also include topics or details that were not addressed in the current session but that the counselor wants to follow up on during the next appointment.
These “STEPs” provide career counselors with a format to efficiently and clearly document their counseling sessions. As one can see from the case study example above, using the STEPs format to document sessions can assist with systematically noting present concerns and planning future goals. The categories provide an organized structure for evaluating progress as well as assessing if career counseling interventions are meeting client needs. The goal of STEPnotesTM is to provide a professional and thoughtful conceptualization of counseling sessions, and to be a useful tool for counselors to note the progress of their clients. More about STEPnotes can be found at www.stepnotesinc.com.
Rhonda Sutton, Ph.D., LPC, LPC-S, is the author of “STEPnotesTM: The Counselor’s Guide to Progress Notes” and president of STEP NotesTM, Inc. She also owns a private career and mental health counseling practice in Raleigh, North Carolina, where she provides career and mental health counseling. For more information, feel free to contact Rhonda via email at firstname.lastname@example.org.
Jeff Dillon Ph.D. on Friday 05/02/2014 at 12:14 PM
Good article-I look forward to reading your book!!
Jeff Dillon Ph.D.
Mental Health/ Career Counselor
Sutter Creek, Calif.
Paul Bredderman on Friday 05/02/2014 at 09:09 PM
Very helpful - I have been struggling with finding a better note-taking format and looking for something like this. Thanks!
Dana D. on Thursday 05/01/2014 at 08:36 PM
Well done. This is excellent and very thorough! Thank you!