That tension was the beginning of the Child-Centered Documentation (CCD) framework.
CCD provides a way to connect referral concerns, diagnosis, treatment planning, caregiver communication, and progress notes while remaining grounded in child-centered values. Instead of focusing solely on symptom reduction, the framework recognizes that meaningful change often begins with internal growth.
As therapists, we often observe shifts in play that suggest children are developing the internal capacities needed for behavioral change. Yet translating those observations into documentation that connects the therapy process to treatment goals, communicates progress to caregivers, and satisfies documentation requirements can be challenging.
Seeing a completed intake, treatment plan, progress note, or caregiver note helps therapists understand not only what was written, but how the clinical thinking connects from one document to the next. It helps make visible the Golden Thread between referral concerns, diagnosis, symptom objectives, growth objectives, and the work happening in the playroom.
That idea became the foundation for a new resource I recently completed, The CCD Documentation Guide for TherapyNotes®.
While the examples are presented in TherapyNotes®, the guide is really about documentation rather than the software itself. It includes examples using both standard SOAP templates and customized note templates, along with a complete Dibs case example that follows the CCD process from intake through ongoing care.
Although the examples are shown in TherapyNotes®, the underlying clinical thinking can be applied within virtually any electronic health record.
One of the things I enjoyed most about creating it was revisiting Dibs in Search of Self through the CCD lens. Dibs is a familiar case for many play therapists, yet it provides a rich opportunity to think about how we connect presenting concerns, case conceptualization, diagnosis, treatment planning, and progress toward internal growth from a child-centered play therapy lens.
Whether you use TherapyNotes® or another electronic health record, my hope is that the examples help make the documentation process feel a little more concrete and a little more connected to the work we are already doing in the playroom.
CCD provides a way to connect referral concerns, diagnosis, treatment planning, caregiver communication, and progress notes while remaining grounded in child-centered values. Instead of focusing solely on symptom reduction, the framework recognizes that meaningful change often begins with internal growth.
As therapists, we often observe shifts in play that suggest children are developing the internal capacities needed for behavioral change. Yet translating those observations into documentation that connects the therapy process to treatment goals, communicates progress to caregivers, and satisfies documentation requirements can be challenging.
Seeing a completed intake, treatment plan, progress note, or caregiver note helps therapists understand not only what was written, but how the clinical thinking connects from one document to the next. It helps make visible the Golden Thread between referral concerns, diagnosis, symptom objectives, growth objectives, and the work happening in the playroom.
That idea became the foundation for a new resource I recently completed, The CCD Documentation Guide for TherapyNotes®.
While the examples are presented in TherapyNotes®, the guide is really about documentation rather than the software itself. It includes examples using both standard SOAP templates and customized note templates, along with a complete Dibs case example that follows the CCD process from intake through ongoing care.
Although the examples are shown in TherapyNotes®, the underlying clinical thinking can be applied within virtually any electronic health record.
One of the things I enjoyed most about creating it was revisiting Dibs in Search of Self through the CCD lens. Dibs is a familiar case for many play therapists, yet it provides a rich opportunity to think about how we connect presenting concerns, case conceptualization, diagnosis, treatment planning, and progress toward internal growth from a child-centered play therapy lens.
Whether you use TherapyNotes® or another electronic health record, my hope is that the examples help make the documentation process feel a little more concrete and a little more connected to the work we are already doing in the playroom.
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