Progress Notes Vs. Psychotherapy Notes

One of the most common questions I’m asked is, “Progress notes vs. psychotherapy notes —what’s the difference?” 

It’s an excellent question. Let’s break it down.

 

What to Include in Progress Notes

In psychotherapy, progress notes establish the progress of treatment. This includes assessment, diagnosis, and treatment protocols, including how the clinician addressed crisis issues and processed them. 

The following kinds of information go into a progress note:

• Medication prescription and monitoring
• Modalities and frequencies of treatment furnished
• Results of clinical tests
• Any summary of the following items: diagnosis, functional status, symptoms, prognosis, and progress to date

The note may be brief, but should include a description of the major events or topics discussed, specific interventions used, your observations and assessment of the client’s status, and any plans you may have for the future. 

You can use structured formats such as DAP (Data, Assessment, and Plan) and SOAP (Subjective, Objective, Assessment, and Plan), or you can use an unstructured format —it’s up to you.

What Is a Psychotherapy Note?

So, what are psychotherapy notes or process notes? They’re sometimes referred to as “private notes.” 

Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private, group, joint, or family counseling session. 

These process notes are separated from the rest of the individual’s medical record.

It’s important that psychotherapy notes exclude the following information:

• Medication prescription and monitoring
• Counseling session start and stop times 
• The modalities and frequencies of treatment furnished
• Results of clinical tests
• Any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date

Companies cannot require you to turn over psychotherapy notes during an audit of your patient records. 

Nor do patients have the right to inspect or obtain a copy of psychotherapy notes. 

However, there are instances where you may be required to turn over psychotherapy notes as required by law, or in compliance with any of the following:

• A court order or court-ordered warrant, subpoena, or summons issued by a judicial officer
• A grand jury subpoena
• An administrative request from a government agency, including an administrative subpoena or summons, civil or authorized investigative demand or similar process authorized by law
• An administrative request in which the information sought is relevant to a legitimate law enforcement inquiry

When considering progress notes vs. psychotherapy notes, you may wonder, “What’s a psychotherapy note supposed to look like?”

It can be in any form that is useful to you and doesn’t need to be readable by others. 

In other words, scribbling in your own personal shorthand is acceptable. They can also be written and stored electronically. 

If you want to quickly and easily track and view your clients’ progress electronically from your mobile phone, tablet, or computer, SimplePractice is a HIPAA-compliant therapist notes software that makes it easy to create and store client therapy notes, assessments, and treatment plans. Check it out by signing up for a free, 30-day trial. 

Think of these notes as a form of self-consultation and preparation for supervision.

Psychotherapy notes or process notes include details of what occurred in a session to put your thoughts and feelings in order, hunches and hypotheses to explore further, and questions to bring up with your supervisor. 

You may also want to jot notes from a supervisory session that you want to include in your thinking for future sessions.

HIPAA protects psychotherapy notes from the blanket release that allows medical information to be used for administrative purposes. It requires that the notes be protected from view by anyone other than the counselor and anyone to whom the records are specifically authorized for release. HIPAA also includes the provision that psychotherapy notes remain separate from the client’s main record.

Until you’re wholly familiar with the nuances of progress notes vs. psychotherapy notes, be sure to bookmark or print out this article to help you remember which types of information to include in each format.

Benefits of Using a HIPAA-Compliant EHR Like SimplePractice 

If you’ve been considering trying out a fully integrated, HIPAA-compliant EHR, SimplePractice gives you everything you need to ensure HIPAA-compliant booking, billing, secure messaging, and telehealth. 

Used by over 200,000 private practice clinicians nationwide, SimplePractice is the practice management software for therapists, speech-language pathologists, occupational therapists, and other practitioners in the health and wellness industry.

Sign up for a free 30-day trial. No credit card needed.

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