Psychotherapy notes
Psychotherapy notes can be as simple as scribbling down a thought during a therapy session with a client. Most clinicians keep some sort of psychotherapy notes but many professionals do not know the definition, purpose, or legal protections behind what they are writing down. Some therapists don’t even have any idea that a psychotherapy note is not the same as a progress note. Here is everything you ever wanted to know about psychotherapy notes.
What is a psychotherapy note?
Psychotherapy notes—also known as process notes—have a legal definition. According to the Department of Health and Human Services, the definition of psychotherapy notes are as follows: “notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date”.
Unofficially, psychotherapy notes are private notes kept by a therapist that are not meant for public consumption. They are a therapist’s thoughts, feelings, and hypotheses regarding a client. For example, you may have a theory about a client’s behavior that you aren’t quite sure is justified but might be important to consider. Psychotherapy notes frequently include questions or concerns that might require follow-up. They do not include identifying information or formal diagnostic information. Most often, they would be taken during a session or right after a session so the therapist accurately remembers what they wanted to say while the session is fresh in his or her mind.
Psychotherapy notes vs progress notes
A progress note is a document of public record and can be shared with others with client consent. Although there is no absolute rule of what should be included in it, many people follow the Subjective, Objective, Assessment, and Plan (SOAP) or Data, Assessment, and Plan (DAP) note format. Generally, as a psychotherapist, you would want to include diagnosis, symptoms, interventions, and a summary of the client’s progress.
Progress notes are designed to be easily digestible to other professionals that may read them. In contrast, psychotherapy notes are for the private use of the therapist and, therefore, can be written in any format or style the therapist desires. Indeed, some therapists quickly jot down impressions that would be unintelligible to anyone else.
Despite the technical differences between progress notes and psychotherapy notes, many therapists use them interchangeably. While hospitals and large agencies may have specific rules to follow regarding notes, therapists in smaller agencies and private practice are not subject to those rules. They may only create one set of notes and not distinguish between psychotherapy and progress notes. This is a personal therapist decision but privacy concerns need to be considered.
HIPAA and psychotherapy notes
The Health Insurance Portability and Accountability Act (HIPAA) offers large protections for psychotherapy notes compared to progress notes. Generally, process notes cannot be shared with others if the therapist does not wish to share the information in them. On the other hand progress notes—usually with a client’s permission—are allowed to be shared with others. In some states, client consent is not even necessary. For instance, office staff may be able to access the information in a progress note without client approval.
In April 2021, the information blocking provision of the 21st Century Cures Act went into effect. In short, this law states that health care providers, including therapists, are required to share clinical notes in electronic health records (EHR) with their clients. While this applies to progress notes, psychotherapy notes are protected and not included under this provision.
It is also important to note that protections for psychotherapy notes include insurance companies. At times, insurance companies will want to audit your records to see if they want to pay for—or continue to cover—mental health services for particular clients. Under HIPAA, you may be required to give them your progress notes, but you are protected from having to share your psychotherapy notes.
Despite the protections afforded to psychotherapy notes, they can still be made public under certain situations. A judge can order a therapist to turn over psychotherapy notes for a legal case or they may need to be divulged under the threat of public safety (i.e., an abusive situation or the client being a threat to themselves or others). Although it would take a more extreme case to have psychotherapy notes released against a therapist’s will, no psychotherapy note is guaranteed 100 percent privacy.
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Can clients access psychotherapy notes?
Generally, no. Psychotherapy notes receive the utmost protection according to the law. Not even the clients themselves can see them without your permission. That includes the parents of minor clients as well. However, a small number of state laws may provide exceptions. For example, in Vermont, clients are allowed to see their psychotherapy notes. This is because Vermont state law offers more protections to clients than is given under HIPAA. The moral of the story: know the privacy laws that apply to your place of practice.
Is there a reason to share psychotherapy notes?
We have established that the privacy of process notes is almost always protected under the law. But that does not mean you can’t show them to other people. Here are some reasons you may want to share them with someone else:
Transferring a client to another therapist
There are various reasons that a client may wish to change therapists. Maybe they are moving out of the area or they just don’t feel like the therapist is a good fit. In any case, it is usual practice to transfer their records to the new clinician. While treatment plans and progress notes should be included, you may wonder if you should also provide psychotherapy notes. You certainly aren’t obligated to do so but they may provide a clearer overall picture of your client’s issues than progress notes alone. Of course, there are potential drawbacks: they may be misinterpreted, misunderstood, or hinder the new therapist from forming objective opinions about the client.
Coordinating care with another professional
It is not uncommon for clients to see another professional as an adjunct to their treatment. For example, seeing a psychiatrist or a nurse practitioner to prescribe psychotropic medication is a regular occurrence when someone is in therapy. While it may be most desirable to obtain consent to speak to them directly, you may also feel it is helpful for another clinician to see your progress and psychotherapy notes. The person prescribing medication, for instance, often has limited information because they usually do not meet with the client as frequently as you do. The more data you can provide them the better. Ultimately, it is more important that they prescribe the correct medication for your client than it is for you to keep your notes to yourself.
Improve treatment progress
It is understandable that therapists would be hesitant to share their psychotherapy notes with their clients. But what if it would help their treatment? In a pilot study, researchers found that participants felt more engaged in therapy as a result of seeing psychotherapy notes about their cases. Yes, a few felt offended by what they read but the large majority of respondents felt it was a good practice that made them feel more invested in their treatment. Of course, you need to be highly sensitive when writing notes If you are considering sharing them with your clients or their family members.
If you are going to release psychotherapy notes to anyone else for any reason, it is required that you get the written authorization of the client. The only exceptions are if you are reporting abuse or neglect, or if there is a significant threat to the client’s safety.
Tips and considerations for psychotherapy notes
1. Even with psychotherapy notes, which have many HIPAA protections, you want to be careful with what you put into them. As mentioned above, no note is entirely confidential. You want to feel free to take down relevant notations but watch for incriminating information. A good rule is to never put down any information you would not want a judge, a lawyer, or the police to be able to see.
2. Psychotherapy notes should exclude the information you might put in a progress note. For example, you would not put prescription medications or demographic information in a process note. It is critical to avoid blurring the boundary between a progress note and a psychotherapy note. If your psychotherapy notes start looking like your progress notes, it could be argued that they should not be subject to more stringent privacy laws.
3. Some therapists develop a shorthand for psychotherapy notes so they do not have to worry as much about someone else getting a hold of their contents. Just make sure you can read your own notes.
4. Psychotherapy notes should always be kept separate from progress notes. If psychotherapy notes are kept with the rest of client documentation, it is not possible to keep them private; it can be argued that they are part of the official record and they will not be protected under the same laws as psychotherapy notes.
5. Know the privacy laws of the states in which you practice. State laws and HIPAA statutes may differ when it comes to privacy. In those cases, whichever is more protective of client rights is usually followed. Therefore, you may believe that your psychotherapy notes are protected by HIPAA only to find out that state law supersedes federal statutes.
6. The police are not entitled to your psychotherapy notes without a court order. While you may feel pressure to turn over all your records if the police request them, you can politely ask that they go to a judge to obtain a court order.
7. If your psychotherapy notes are subpoenaed, that does not necessarily mean you have to hand them over.
You can take the following actions to attempt to keep them from becoming public:
- First, make sure that your psychotherapy notes are specifically being requested. If there is only a general request for a client’s records, then you are not obligated to hand over your process notes.
- Negotiate with the person requesting your notes. This is likely a lawyer. There is no rule that says you can’t contact the lawyer and negotiate with them. It may not always work but it is worth a try.
- File a motion to quash. This is a formal request you make to the court to prevent having to provide the requested information. You will state the reasons you feel the information should not be shared.
- File a protective order. This is somewhat of a compromise. You agree that you will provide the requested information but you want to define who is allowed access to it. It is an attempt to limit any negative consequences of having the information disclosed.
- Make sure the request for records is from a judge. In certain states, a lawyer can write their own subpoena that might not hold up when challenged.
Psychotherapy notes are an integral part of treatment that are protected under stringent privacy laws. For that reason, you want to make sure to keep them separate from a client’s progress notes and the rest of their medical record. But how do you keep them apart if you are keeping electronic health records (EHR) on a computer? Theraplatform is here to help. It is an all-in-one teletherapy, EHR, and practice management software for therapists and medical professionals. It is HIPAA-compliant and allows you to keep psychotherapy notes separate and secure from the rest of the medical record. What’s more, it has templates for all kinds of notes and even allows you to customize them from scratch. So, don’t waste time wondering if you are complying with HIPAA and keeping your client’s information secure. TheraPlatform, an all-in-one EHR, practice management and teletherapy tool was built for therapists to help them save time on admin tasks. Start a 30-day free trial of Theraplatform today.
Resources
More resources
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice
