The Art of Charting
Social Work Today
By Karl D. LaRowe, MA, LCSW
Vol. 4 No. 3 p. 36

Why do we hate charting so much? It is almost universal in every workshop I give on “How to Transform Compassion Fatigue”: Care providers hate chart work. Charting may well be the single most detested activity professional caregivers share in common. Why? What is it about documenting the interaction between you and your client that can lead to increased stress and avoidance?

Bring to mind the last time you “forced” yourself to do chart work that “should have” been done and notice where in your body you begin to feel tense. Do you tighten the muscles that connect your shoulders and neck? Are you holding or restricting your breath and stomach? Is your attention out of alignment with your intention?

Secondary Traumatic Stress Disorder
B. Hudnall Stamm, PhD, describes secondary traumatic stress disorder as “a syndrome of symptoms nearly identical to PTSD [posttraumatic stress disorder], except that exposure to a traumatizing event experienced by one person becomes a traumatizing event of the second person.”

For many care providers, the act of writing chart notes can precipitate a secondary traumatic stress reaction. This reaction is particularly evident when the care provider is also a trauma survivor and is helping a client whose trauma is similar to the care provider’s.

The fact is that we see each client twice: the first time in person and the second time writing the chart note. Every time you sit down to write a chart note, you must first place yourself back to the interaction with your client as it is recorded in your memory—both implicit and explicit memory.

Implicit memory is also called body memory. It is the feeling and emotional and physical memory of the event that is recorded in the body, not just in the brain. The more intense the memory, the more indelible the mark that is etched into implicit memory.

This process is often why you tense your muscles and hold your breath as you chart certain clients. Your body is responding to the implicit memory of absorbing and internalizing the traumatic energy in motion of your client. In essence, your body is experiencing a miniature retraumatization as you force yourself to chart.

Transforming Chart Work to ArtWork
Transforming an activity that you detest doing into something that you can begin to feel positive about may require that you move from a point of view to a viewing point. This movement means letting go of the need to be right and accepting that if your current way of perceiving and doing chart work isn’t working for you, you must be willing to let it go. For there to be change, we must first be willing to change.

The next step is to surrender to the reality that you will probably always be doing chart work so long as you are a professional care provider. It is an almost certain, inevitable reality. To work in most of the professional caregiving fields today, you will be required to document your interactions with clients. Surrendering is the warrior’s art; it is giving in without giving up.

Next, as much as you are able, do the charting immediately after seeing the client. I know and hear many reasons why that’s not possible for everybody—accepted.
To the best of your ability—and I would hope there is good support for this—chart as soon after seeing the client as possible. This practice has at least three advantages:
1. The images, emotions, and body sensations are fresher. They have not had the time to etch into your body as implicit memory.
2. Your explicit memory is sharper, more objective, and more accurate.
3. You are taking a positive and specific step in reducing stress and increasing your sense of flow and enjoyment.

The next step is preparation. Each time you sit down to chart, go in with your eyes open. Be fully conscious of the potential effect that revisiting your interactions with clients can have on your perception, emotions, and body. Do not minimize the effect secondary traumatic stress can have on your sense of self.

Getting into the Flow
“Even the simplest physical act becomes enjoyable when it is transformed so as to produce flow. The essential steps in this process are:
(a) to set an overall goal, and as many sub-goals as are realistically feasible;
(b) to find ways of measuring progress in terms of the goals chosen;
(c) to keep concentrating on what one is doing, and to keep making finer and finer distinctions in the challenges involved in the activity;
(d) to develop the skills necessary to interact with the opportunities available; and
(e) to keep raising the stakes if the activity becomes boring.”

— Mihaly Csikszentmihalyi, “Flow: The Psychology of Optimal Experience”

Charting can become an art form when done with the conscious intent to align who you are with what you are doing. Getting into the flow requires letting go of your internal resistance to doing chart work and allowing yourself to develop a sense of enjoyment and mastery from being absorbed in the activity itself. The next time you chart, try the following steps:
1. Slow down for a moment. Pause. Relax. Take several deep breaths. Quiet your mind. Guide your attention inward.
2. Take in slow, deep breaths from your diaphragm. As you breathe, gently circle your shoulders forward and up as you breathe in, then back and down as you exhale with a sigh of relief.
3. As you begin to write in the chart, sense with your feelings that the emotion or energy in motion you empathically absorbed from your client is flowing from your heart and/or gut, into your arm, hand, and out of the pen (or keyboard) as you write.
4. As you get into the flow of writing, continue to focus on being in the present moment, inside your body. If your mind should wander, gently bring it back to your here and now present reality.
5. Allow yourself to get absorbed in the activity. Begin to notice how you are able to “get yourself out of the way” to allow a stream of consciousness that may begin as a body or feeling memory and is effortlessly translated into written words.
6. As you flow in greater synchronization between internal feeling states and their external expression in words, allow yourself to feel and absorb a sense of enjoyment and mastery.
7. Each time you think about doing your charting, allow your increasing enjoyment and sense of mastery to be the preferred memory.

— Karl D. LaRowe, MA, LCSW, is a licensed clinical social worker, mental health investigator and examiner, and international speaker on traumatic stress, depression, and compassion fatigue.