Solution-Focused Documentation

Embedding solution-focused documentation templates within electronic health records could help build solution-focused fluency, sustain solution-focused practices within organizations, and improve care coordination, communication, and client outcomes.  Thank you for reading this article on solution-focused documentation, which I would venture to say is not the most exciting topic. How did you decide to take the time while working tirelessly on the front lines of the mental health pandemic, given how staying up to date on notes is the miserable bane of our daily grind?  As my colleagues used to say, a “note is just a note” and “a done note is a good note,” but notes (documentation) now serve so many additional purposes, including accountability to reimbursing third parties, accreditation agencies, legal records of care, informing clinical decision supports and creating a repository of information for clinical research and quality improvement initiatives. Medical and mental health professionals are required to complete all sorts of documentation such as comprehensive psychological intake assessments and ongoing documentation to determine whether a client is appropriate for counseling,  what types of treatment are indicated, formulating treatment plans, coordinating care with multiple providers, documenting when clients are ready to complete or  “graduate” from discrete treatment episodes, and whether a higher level of care is indicated, such as in emergency and crises. However, little empirical attention has been given to this intake and subsequent paperwork (Richmond et al., 2014), and there is little evidence in the literature to guide the selection of specific data entry methods according to the type of data documented (Wilbanks 2018). 

Primary care and behavioral health clinicians often differ in their reporting requirements, codes, regulations, and language. Working with clinical teams to create solution-focused customized shared templates that are unique to each practice context is essential. Providing practitioners within organizations the opportunity to review their current documentation forms, get input directly from clinicians, and test out the forms with practitioners is essential for successful implementation.  Incorporating solution-focused questions within semi-structured data entry by creating text narratives and structured data entry could harness positive aspects of electronic records (Janett & Yeracaris 2020). 

At the end of this article, there are solution-focused documentation examples for an intake evaluation, a progress note with a case example, and a solution-focused safety assessment (SFSA).

Solution-Focused Brief Therapy entails a paradigm, order, and language shift. These components can be easily integrated into documentation templates to enhance practitioner fluency and assist in sustaining the solution-focused brief therapy approach within organizations. 

Documentation is considered static and unchanging; however, what questions are asked, how they are asked, and when they are asked all make a difference in the narrative created.  The solution-focused practitioner harnesses hope by assisting clients in developing a narrative in which they can recognize their agency and resources while developing an action plan moving forward. Solution-focused documentation can help clinicians and clients develop a hopeful report while making record keeping a little more tolerable and bearable for practitioners. 

Solution-focused brief therapy (SFBT) is fundamentally a linguistic therapeutic approach. Questions are constructed to convey confidence in the client while simultaneously recognizing their agency, strengths, and resources and creating a collaborative treatment plan with the client.  Questions are formulated to help clients articulate what has worked, what is working, and what their best hopes are so they will be confident and have the necessary “good enough” skills to graduate from defined treatment episodes.  The solution-focused practitioner attempts to highlight positive language while simultaneously conveying a belief and confidence in their client. Solution-focused documentation templates can provide friendly reminders and cues for clinicians to ask hopeful questions.  What questions we ask, what we listen to, what we ignore, how we construct questions, and what order we ask questions matter. 

Imagine if the following questions were part of an electronic record semi-structured document. 

• • “What are your best hopes?”: conveys the assumption that they do have best hopes.
  • “What has been better since we last met?: conveys something has been better and looks for positive differences/exceptions.
  • “What has been happening that you want to continue to happen?” conveys some things have been working.
  • “What do you know about your condition?”: conveys that they do have knowledge and expertise. 
  • “What do you know about your child that they will succeed in life?”:  conveys a belief that they do know their child will succeed. 
  • “Supposing ten is you are confident that your skills are good enough to graduate from this treatment episode, and 1 is the opposite; where are you now?”: conveys clients have the capabilities to develop skills and graduate from discrete treatment episodes.

Traditional intake and follow-up paperwork have relied on a medical model that requires a detailed description of the client’s problems. Problem-oriented approaches require a complete understanding of all the symptoms to make a diagnosis and then treat the client. Solution-focused brief therapy (SFBT)  stands in sharp contrast. SBFT is the only therapeutic modality not requiring a complete understanding of the problem for clients to move forward with their goals. SFBT starts by revealing a detailed understanding of the client’s best hope for their future and collaboratively looks for client-related resources, actions, and agency that build this outlook. The focus is on detailing what a client will do when their problem is solved rather than diagnosis and symptom exploration. Based on the premise that people have the necessary resources to solve their problems, SFBT amplifies these strengths and abilities by building a shared dialect that focuses on what has worked and is working in a client’s life.  

Resource activation and therapeutic interventions that reinforce the client’s agency and abilities play a central role during successful treatment (Gassmann & Grawe 2006).  Therapists who create an environment where clients perceive themselves as well-functioning and activate their resources early in the session have more successful outcomes (Gassmann & Grawe 2006). Research was done to test problem-focused versus solution-focused intake questions on pre-treatment change and compared a standard written intake form with problem-focused questions to a solution-focused brief therapy intake form (Richmond 2014). Clients answering the solution-focused questions described significantly more solutions and fewer problems than the comparison group. Clients in the SFBT intake interview improved significantly on the Outcome Questionnaire before their first therapy session, whereas those in the traditional diagnostic intake did not. This study demonstrated that intake procedures are not neutral information gathering and that strength-based questions have advantages (Richmond 2014). 

The following is a brief example of a case and one possible way to incorporate solution-focused documentation. Of course, there are many different mandates and requirements; this example only provides one. All documentation templates need input from staff and organizations to ensure they meet requirements.

Karl is an 18y/o transgender male (preferred pronoun is he) who presented to the emergency department following a motor vehicle accident. He reportedly was texting his friends about meeting to hang out with them while driving when he didn’t realize the car in front of him had stopped. The car was totaled. Karl sustained a broken leg and back injury. He was hospitalized due to the severity of his injuries and the need for surgery on his leg. While awaiting surgery, Karl was reporting suicidal thoughts and wanting to die. Karl’s father was out of town caring for his elderly parents on the car accident day and had not yet arrived back home. Karl had a difficult time when his father was away and had a prior overdose attempt six months ago while his father was caring for his elderly parents. Karl’s mother died from cancer when Karl was 12 years old, and Karl spent much of his youth witnessing her treatments, decline, and death. The following is an excerpt from Karl’s crisis evaluation while in the hospital medical unit.

Tx: Hello Karl – is that how you like to be called?
Karl: Yes
Tx: Thank you for taking the time to meet with me. My hope is that I will be helpful to you. I will do my best. Would it be ok if I asked you a few questions in hopes of being helpful for you? Some questions may be a bit challenging.
Karl: Ok
Tx: Thank you. It must be difficult for you to be here; how have you been holding up these past few days?
Karl: It’s been hard. It’s loud, and I can never get any rest. I just want to go home.
Tx: Of course. It must be so frustrating for you to be here. What do you know has helped make things even a little bit bearable while you are here?
Karl: Getting pain medication.
Tx: How has getting pain medication been helpful for you?
Karl: It was bad after the accident. I was in so much pain. All I could think of was killing myself just to relieve my agony.

The therapist sets the tone by thanking Karl and confirming how he wants to be called, as well as providing consent for the conversation to follow. The therapist also provides plenty of “for you” responses followed by coping questions that activate Karl’s individual resources early in the conversation.

Tx: I’m glad the medications are being helpful for you. How well would you say you are tolerating your pain from 1-10 (10 being the best)?
Karl: Probably a 5.
Tx: What would be a good enough number?
Karl: A 7.
Tx: What keeps the number from being lower than a 5?
Karl: I’m able to get some sleep.
Tx: What else keeps it from being lower?
Karl: It’s gone up from a one, and I’m hoping the surgery will help even more.
Tx: What have you done that has helped the medication work, even a little bit?
Karl: I just try and distract myself by playing video games. The nurses have brought me some games, and that helps a bit.

The therapist attends to his pain and how well he is tolerating it demonstrating concern about his wellbeing. Scaling how well Karl is tolerating the pain and how helpful the medications are from 1-10 is a more constructive way to assess pain. It promotes his agency in managing his pain.

Tx: I’m impressed with how you are handling this. I wonder if you know whose idea it was for me to come and see you today?
Karl: I think it was the nurse.
Tx: What do you know the nurse was concerned about that asking me to come to see you would be helpful for you?

Asking Karl whose idea it was for the therapist to come and framing this as concern can be helpful in exploring important VIPs in Karl’s immediate social context. Notice that the therapist did not ask “why” rather instead what the nurse was concerned about guiding the narrative to one of care and compassion.

Karl: I don’t know. (Pause) Probably because I said I wanted to die and couldn’t take it anymore.
Tx: What do you mean by “take it anymore”?
Karl: My father is in Arizona, and when he comes back, he will be furious with me. I know he will take away my driving privileges, and driving to see my friends is the only thing that helps me feel any better.

Karl was able to identify the reason for the consultation – that he wanted to die. Exploring the meaning of his words provided more about Karl’s concerns and his reasons for distress. Although, it may seem to slow the conversation down, exploring the clients’ meaning often paradoxically moves the conversation forward more quickly as the therapist and client negotiate a shared understanding.

Tx: That must be very difficult for you to think about while also dealing with your pain and upcoming surgery. How have you been enduring all of this?
Karl: It’s been hard. My father is still in Arizona and won’t be home until tomorrow.
Tx: Of course, this must be hard for you. Is your father an important person in your life?
Karl: Yes. I don’t know what I would do without him.
Tx: What do you most appreciate about your father?
Karl: He’s always there for me – even when I do stupid things. He doesn’t give up on me.
Tx: What has he done to always be there for you?
Karl: He and I are close. After my mother died, we went through a lot. We helped each other.
Tx: It sounds like your father loves you a lot. Suppose I were to ask him what he most appreciates about you, what would he say?
Karl: That I’m strong, and I can deal with a lot.
Tx: What do you mean by “deal with a lot”?
Karl: My mother died when I was 12 years old, and it was so hard.
Tx: That sounds incredibly challenging. What would your father say you have done to deal with this?
Karl: He’d say that I kept going to school and kept caring about people – that I am strong.
Tx: What would he say you have done that you are strong?
Karl: That I care about people.
Tx: You both sound very strong. I’m wondering, who else are the important people in your life?
Karl: My mother. Even though she died, I think of her a lot and know she is with me.
Tx: What do you suppose your mother most appreciates about you?
Karl: She knows how much my father and I care and help each other. She would be proud of that.
Tx: What else would she say she appreciates about you?
Karl: That I don’t give up.

Taking the time to ask who the most important people in Karl’s life and what they most appreciate about him is critical in highlighting his relationship resources. It is often these meaningful relationships that are protective and stop people from acting on thoughts of suicide.

Tx: Supposing I asked your mother and father what their best hopes would be for you so they would know you are safe to go home, what would they say?
Karl: My father would want to make sure I don’t do anything unsafe.
Tx: What would he hope you do instead?
Karl: He would want me to let him know if I was upset and reach out for support.
Tx: What else would tell him you can keep yourself safe?
Karl: That I wouldn’t be driving and getting into accidents and wanting to end my life. I don’t want to die; it’s just sometimes I get so upset that all I can think of is the relief of being together with my mother.
Tx: Of course. These are very intense emotions you are experiencing. I’m wondering, what are your reasons for living?
Karl: I want to go to college and become a nurse.
Tx: Wow. That is impressive. Have you always wanted this, or is this different?
Karl: I’ve wanted to be a nurse for a long time. Ever since seeing how they helped my mother and our family.
Tx: Wow – you are strong. Where do you get this determination from?
Karl: Probably my father. He doesn’t give up. He keeps trying to help his parents and me.

Often clients experiencing intense emotions are more able to answer what their best hopes are from the perspectives of their VIPs. This is another reason to have some knowledge of who are the most important people in your clients’s life. Karl was able to answer what his parents’ best hopes were quite easily – to stay safe. Following this, every question or response was focused on activation of his resources including exploring his reasons for living. This is in contrast to exploring why he wants to die. Exploring his reasons for living uncovered additional resources and opportunities to compliment Karl and explore positive differences with him.

Tx: Sometimes, I ask number of questions to help me help you. Would that be ok?
Karl: Ok
Tx: Suppose ten is you are confident that you can keep yourself safe and one is the opposite; where are you now?
Karl: about a 5.
Tx: And what would be a good enough number?
Karl: A 6
Tx: What keeps the number from being lower than a 5?
Karl: Knowing that my father will be here soon.
Tx: What do you know about your father being here for you soon is helpful?
Karl: I just need to have him nearby. He knows how to calm me down.
Tx: What else keeps the number from being lower?
Karl: That I wouldn’t do anything. I wouldn’t want to hurt my father. It would kill him.
Tx: Suppose I asked your father how confident he is in terms of your ability to keep yourself safe from 1-10; what would he say?
Karl: I don’t know.
Tx: You know your father best. There is no right answer. I’m just wondering what you think?
Karl: Probably a 3
Tx: What do you think is the reason your number is a 5 and not a 3?
Karl: I think he would say he’s scared that I had another accident and did the same thing a few months back. He would probably say he’s scared that I could’ve died.
Tx: of course – I’m sure that must be frightening for him to know you could have died. What do you suppose keeps his number from being lower than a 3?
Karl: That I’m here and getting help.
Tx: What else do you think keeps his number from being lower?
Karl: That he’s on his way and will be here soon.
Tx: I’m wondering, Karl, what would you be doing when your confidence is just a bit higher, at a 6?
Karl: I would have a plan for when I leave the hospital.
Tx: What do you mean by a plan?
Karl: That my father and I would talk, and I would have someone to talk to.

Scaling confidence in Karls’ ability to stay safe and “working the scale” is an effective way to develop a collaborative safety plan. Even though his parents were not present in the session, their perspectives could easily be incorporated into the conversation. Numbers limit language confusion and allow for a clear plan moving forward in small manageable steps. Numbers often help clients manage the intensity of their experiences safely, as working the scale provides further opportunities to highlight their agency and a plan. And Hope = agency + plan!

These document examples are provided as PDFs.

Karl Progress Note case example

Solution-Focused Progress Note

Solution-Focused Adult Intake Questionnaire

Solution-Focused Safety Assessment Tool

Beyebach, M., Neipp, M. C., Solanes-Puchol, Á., & Martín-del-Río, B. (2021). Bibliometric Differences Between WEIRD and Non-WEIRD Countries in the Outcome Research on Solution-Focused Brief Therapy. Frontiers in Psychology, 4926.

Gardner, C. L., & Pearce, P. F. (2013). Customization of electronic medical record templates to improve end-user satisfaction. CIN: Computers, Informatics, Nursing, 31(3), 115-121.

Gassmann, D., & Grawe, K. (2006). General change mechanisms: The relation between problem activation and resource activation in successful and unsuccessful therapeutic interactions. Clinical Psychology & Psychotherapy, 13(1), 1–11.

Janett, R. S., & Yeracaris, P. P. (2020). Electronic Medical Records in the American Health System: challenges and lessons learned. Ciencia & saude coletiva, 25, 1293-1304.

Richmond, C. J., Jordan, S. S., Bischof, G. H., & Sauer, E. M. (2014). Effects of solution-focused versus problem-focused intake questions on pre-treatment change. Journal of Systemic Therapies, 33(1), 33.

Wilbanks, B. A., & Moss, J. (2018). Evidence-based guidelines for interface design for data entry in electronic health records. CIN: Computers, Informatics, Nursing, 36(1), 35-44.