, Volume 32, Issue 1, pp 22-38
Date: 12 Dec 2009

How Master’s Students Document Stability and Change Within and Across Progress Notes

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Abstract

To address a gap regarding how clinicians record progress in therapy, the researchers conducted a qualitative study of de-identified progress notes from a university-based brief therapy training clinic. The researchers described trainees’ stability and change documentation with respect to problem-oriented and solution-oriented talk in their progress notes. The patterns were (a) problem-oriented stability and problem to solution change within first sessions; (b) problem-oriented and solution-oriented stability within last sessions; and (c) stability (e.g., problem to problem) and change (e.g., problem to solution) across first and last sessions. Findings suggest that first session problem and solution outcomes do not necessarily predict last session outcomes (i.e., problem continuation or change to solutions).

An earlier version of this paper was presented October 5, 2008, as part of a symposium entitled, “Constructing Clients in Clinical Texts: Qualitative Investigations of Marital and Family Therapy Intakes and Progress Notes” at the 14th International Interdisciplinary Qualitative Health Research Conference, Banff, Alberta, Canada.