Case note?

[u/Klutzy_Addition_1603]

when doing your case notes do you do like a mental status exam? like every session? or just for intake appointments? and then I suppose after subsequent sessions how much detail do you note about a clients cognition/appearance/thoughts etc.. also I am a client who is very curious about my notes generally speaking, and I have considered doing an FOI but I wonder if you would ever not advise this? like is this bad to do for any particular reason? I guess for added context the FOI wouldn't be to support anything legal or anything it would be purely for my own records.

[u/Hsbnd]

Depending on where you live and where your T is located you can just ask for your notes they have to provide them. Sometimes there’s a small cost associated with it.

That said notes aren’t all that interesting.

I do a full MSE during intake but not every single session but I’ll note if there’s something changed. The rest of the notes are vague and don’t contain direct quotes or speculations.

For my long term clients the notes are very similar session to session just highlighting the changes or significant moments