Woman's hand writing in a notebookAs a therapist, you might use psychotherapy notes, also called private notes or process notes, to organize your thoughts and observations about each session. These notes might involve content of your sessions with a single client, couple, or group.

You might use psychotherapy notes to keep track of your progress in therapy and any ideas you have about topics for future exploration. These informal notes aren’t required, so you can maintain them privately and keep them confidential. Since you don’t have to share them, you can include more detail than you might in the official notes you use for insurance or treatment purposes.

If you keep these notes secure in your office, in a notebook or other written format, you probably don’t have to worry about privacy concerns. But if you take therapy notes in a digital format, you’ll have to make sure they’re not only separate from the required progress notes but also safeguarded against potential privacy breaches.

Below, we’ll answer some common questions you might have about therapy notes, including how to make sure they don’t violate HIPAA.

Writing Psychotherapy Notes: Common Questions and Answers

1. Should I keep digital or handwritten notes?

When it comes to the type of notes you take, it mainly depends on the format you feel most comfortable with. If you prefer to write by hand, you may find your words flow more freely than if you try to type up your thoughts. You might also find it more difficult to organize handwritten notes and prefer a digital format.

If you do keep digital therapy notes, you’ll need to make sure they stay separate from progress notes and treatment information. They also must comply with HIPAA. If you’re already using HIPAA-compliant software in your private practice, this shouldn’t pose any additional challenges. Learn more about HIPAA-compliant therapy software here.

2. Are my digital psychotherapy notes HIPAA-compliant?

If you store your therapy notes on your computer, they should be protected in the same way as your other client information. Keep in mind that therapy notes are confidential and remain on your computer, so you don’t have to worry about taking extra steps to secure them when sending them electronically. If your computer is secure and no one else has access to it, you might choose to keep your therapy notes in a Word document that you save in a password-protected folder, for example.

But if you’re using any type of HIPAA-compliant software for your private practice, you’ll most likely be able to create therapy notes with the software. This will guarantee HIPAA compliance.

3. What if my client asks to access my psychotherapy notes on our sessions?

Therapy notes are private, so you don’t have to show them to your client, according to federal law. You can choose to share them, if a client asks, but many states allow you to make this decision yourself. Some states do require you to share the notes if a client asks for them, so you’ll want to stay informed about the laws in your state.

These notes include your private thoughts about what takes place in therapy, such as observations or feelings about discussions you have with your client. The concern behind sharing them typically is that these notes could cause harm to the client. They don’t include any information about medication, treatments, diagnoses, or test results, so they generally wouldn’t help the outcome of treatment.

4. How are psychotherapy notes different from progress notes?

Progress notes contain information directly relevant to treatment, such as a diagnosis, prescription for medication, type of therapy, or mental health symptoms. You might share this information with your client, family members they allow you to disclose to, and your client’s other care providers. Blake Edwards, MSMFT, a licensed marriage and family therapist in Wenatchee, Washington, explains how thought should also be given to progress notes. "Therapists must learn to walk the line between putting in enough information to indicate how session interventions and response to interventions align with the established treatment plan without putting in too much information," he shares. "Remember, notes are audited and can be subpoenaed. They also may be later read by clients themselves. Ultimately, each note both stands alone and plays a role in telling a larger story within the treatment record."

Psychotherapy notes don’t contain any of this information. In general, therapy notes are limited to conversations that take place in the therapy session and your thoughts about those conversations. For example, if something your client says disagrees with something they said in a previous session, you might note this so you can mention it to them at a future session.

5. Is taking notes making my client nervous?

Taking copious notes during a session can put your client off or make them feel nervous. Your attention should, for the most part, remain on what the person in therapy has to say. If you seem distracted by your notes, they might wonder what you’re writing or feel as if you aren’t listening to what they’re saying.

It’s generally best to keep note-taking during the session to a minimum. It can help to jot down brief thoughts and formulate sentences from these notes later. You might use shorthand, symbols, or other methods to help you keep track of your thoughts.

Taking notes on a laptop, tablet, or other device may be even more distracting, so you may want to stick to paper and pen during the session and type up your notes later. You can always ask your client how they feel about you taking notes, but they may not always feel comfortable telling you exactly what they think.

Recording your session may seem helpful, and this can in fact have benefit to both you and your clients, but you’ll need to get consent in order to make recordings of your sessions.

Conclusion

You don’t have to take therapy notes, but they can help you sort out your thoughts after a session. You don’t need to write down everything your clients say, though, and it’s important to pay attention to how your clients react to note-taking. If they seem distracted or bothered by your taking notes, you can always bring up the issue and use this as an opportunity to strengthen the therapeutic relationship.

References:

  1. American Psychological Association. (2007). Record keeping guidelines. American Psychologist, 62(9), 993-1,004. doi: 10.1037/0003-066X.62.9.993
  2. Barnett, J. E. (2009). Ask the ethicist: The role of recording in psychotherapy. Retrieved from http://www.societyforpsychotherapy.org/ask-the-ethicist-the-role-of-recording-in-psychotherapy
  3. Holloway, J. D. (2003). More protections for patients and psychologists under HIPAA. Monitor on Psychology, 34(2), 22. Retrieved from https://www.apa.org/monitor/feb03/hipaa
  4. How to maintain HIPAA compliant psychotherapy notes. (2018, February 20). Retrieved from https://www.theranest.com/blog/are-your-psychotherapy-notes-hipaa-compliant
  5. Nicholson, R. (2002). Dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38-39. Retrieved from https://library.ahima.org/doc?oid=58162#.XTZ7RNNKjOS
  6. Organization policy on the use or disclosure of psychotherapy notes for research (Policy No. HIPAA 164.3). (2007). Retrieved from https://www.hopkinsmedicine.org/institutional_review_board/hipaa_research/164_3.html