Psychotherapy Notes

Psychotherapy notes are notes taken by a mental health professional for the purpose of documenting or analyzing the content of a conversation during a therapy session. They are also sometimes referred to as process notes or private notes.

What Are Psychotherapy Notes?

Mental health providers are required to document their sessions through the use of progress notes, which are designed to provide an outline of the basic information about what occurred during a session. Psychotherapy notes, on the other hand, are not required, but many therapists use them as a way to conceptualize the case, document their own thoughts and feelings from each session, and list hypotheses to further explore in future sessions.

Psychotherapy Notes versus Progress Notes

Progress notes are intended to document the progress of treatment. They typically include information about the presenting symptoms and diagnosis, observations and assessment of the individual’s presentation, treatment interventions used by the therapist (including modality and frequency of treatment), results of any tests that were administered, any medication that was prescribed, and a summary of the individual’s progress in treatment. Progress notes may also include information about any crises that emerged and how the therapist addressed them. These notes are typically limited in their scope because they are subject to being shared with those in treatment as well as outside parties, such as insurance companies.

Psychotherapy notes are often more detailed and go into greater depth than progress notes because they are meant to help practitioners conceptualize the case, gather their thoughts, and make note of their impressions and feelings. These notes may contain information that would be inappropriate for the medical record and is not meant to be shared with other parties. Psychotherapy notes are intended to be used solely by the therapist who is writing them. As such, they are granted a special degree of confidentiality.

Psychotherapy Note Templates

Clinicians often use a template for their progress notes, such as the DAP or SOAP format. Notes in the DAP—data, assessment, and plan—format typically include data about the individual and their presentation in the session, the therapist’s assessment of the issues and progress, and a plan for future sessions. SOAP stands for subjective statement, objective data, assessment, and plan, and notes in this format include information similar to those in DAP format, with the addition of a subjective or summary statement from the individual about how they are feeling.

Psychotherapy notes can be documented in any form that is useful to the therapist, and they often do not follow a specific template. Because they are meant to be used only by the therapist who is writing them, they can be documented in shorthand and do not have to be legible to others.

HIPAA and Psychotherapy Notes

Psychotherapy notes are given special protection under HIPAA. While individuals have the right to inspect and request copies of their medical record, they do not have the right to access their psychotherapy notes. If a psychologist denies an individual access to psychotherapy notes, that denial is not subject to the review process that s standard with other records. Additionally, psychotherapy notes are protected from third-party payers such as insurance companies. Health plans cannot refuse to provide reimbursement for treatment based on an individual electing to keep their psychotherapy notes private. It is important to note, however, that these extra protections given to psychotherapy notes only apply to notes that are kept separate from the rest of an individual’s record.

References:

1. DAP notes, SOAP notes, and therapist confidential notes. (n.d.). Retrieved from http://maretwebproject.com/users/docs/session_notes.pdf
2. Holloway, J. D. (2003). More protections for patients and psychologists under HIPAA. Monitor on Psychology, (34)2. Retrieved from http://www.apa.org/monitor/feb03/hipaa.aspx
3. Spector, H. (2014, October 2). Progress note or psychotherapy note: Are you sure you know the difference? Retrieved from https://www.simplepractice.com/blog/progress-note-or-psychotherapy-note-are-you-sure-you-know-the-difference

Last Updated: 01-13-2017