Psychotherapy Notes

Psychotherapy notes are personal reflections recorded by therapists during or after sessions to aid memory and enhance client care.

This article discusses  psychotherapy notes, including examples of psychotherapy notes, the differences between progress notes and psychotherapy notes, who can access psychotherapy notes and when can psychotherapy notes be disclosed, and much more.

If you have ever taken a note during a session that wasn’t meant to be included in the client’s official record, or written a note to yourself in a clinical journal after a session, then you have probably taken psychotherapy notes.

Most clinicians I typically talk to utilize some kind of memory jogger, or unofficial recording of their client interactions, but aren’t as familiar with the intricacies and specificities involved in the psychotherapy notes format.

As a therapist and private practice owner, understanding the nuances of psychotherapy notes is essential for both effective client care and legal compliance.

This article delves into these intricacies, offering insights into their purpose, content, and legal considerations—including what you need to know about HIPAA and psychotherapy notes.

In addition, this article includes best practices for documentation—sharing various examples of psychotherapy notes you can model your own notes off of.

Understanding psychotherapy notes

Psychotherapy notes are the personal notes taken by mental health professionals during or after a therapy session.

So, if you’re a therapist who sits with a pad and pen and makes small notes you don’t want to forget during sessions, you may unofficially be using psychotherapy notes.

These notes document or analyze the contents of conversations during private counseling sessions and are kept separate from the client’s medical record. They are intended to aid the therapist’s memory and are not typically shared with others.

As counselors, we don’t typically think of these small notes as being a part of a client’s record, and while they are separate from a client’s medical record, it’s critical to understand their purpose and requirements.

Purpose and importance

The primary purpose of psychotherapy notes is to assist therapists in recalling specific details of therapy sessions to facilitate continuity of care.

Psychotherapy notes may include impressions, hypotheses, details from the session, and thoughts that are not appropriate for the formal medical record, but are valuable for therapeutic progress.

While it would be great if therapists could remember small details and every bit of their inner-dialogue during each session, for most of us, this is unrealistic.

Most therapists see between 20 and 30 clients a week—sometimes up to 10 clients in one day. Since so much time is spent one-on-one with clients, therapists may not always remember the details required to provide the highest level of care.

As a result, some clinicians end up mixing up client names and case details—mistakes that can affect the therapeutic alliance and compromise the ethical responsibility clinicians have to maintain client confidentiality.

Psychotherapy notes serve as an important support for therapists who would otherwise not remember important details for their cases.

Psychotherapy notes vs. progress notes 

First, let’s distinguish the difference between psychotherapy notes and progress notes. Progress notes are part of the official medical record and include information such as diagnosis, treatment plans, session start and stop times, and clinical impressions.

Progress notes are more likely to be requested either by another provider, if relevant to the client’s treatment, or by a judge, if subpoenaed in a court case. For example, progress notes can be subpoenaed by a judge in a custody case if a client’s custody arrangement is conditional on ongoing treatment.

In contrast, psychotherapy notes are kept separate from a client’s medical records, and contain more detailed personal observations and thoughts of the therapist. Typically, small details are kept as a memory jogger for the therapist, such as the therapist’s impressions, hypotheses, and thoughts not appropriate for formal documentation.

Understanding the distinction between psychotherapy notes and progress notes is crucial, as the former receives special protection under HIPAA due to their sensitive nature.

Although kept separate, it’s still possible for psychotherapy notes to be subpoenaed and therapists should be mindful of what data they collect and put in writing.

To maintain confidentiality and comply with legal standards, therapists should store these notes securely, use clear and concise language, and periodically review their relevance.

By adhering to best practices, clinicians can effectively utilize both psychotherapy and progress notes to support therapeutic progress while upholding ethical and legal responsibilities.

The primary differences between progress notes and psychotherapy notes are in their purposes—the former is for documenting treatment, while the latter serves as a memory jogger.

Due to their different purposes, there are different implications for the legal constraints and storage requirements for each. Psychotherapy notes can be stored anywhere as long as they are kept private and inaccessible to unauthorized entities or people. Since they will still likely include client PHI (personal health information), precautions should be taken to ensure the client’s confidentiality.

On the other hand, progress notes must be stored in a HIPAA-compliant practice management software as a part of a client’s medical record, or in a properly secured physical file of the client’s medical record.

Now that we understand the purpose of a psychotherapy note, we can dive into what the contents of a psychotherapy note typically consists of.

What is part of the psychotherapy notes? 

Psychotherapy notes may include:

• Any detailed observations about the client’s behavior and statements.
• Therapist’s hypotheses and impressions that can further inform diagnosis or drive treatment.
• Personal thoughts and feelings of the therapist regarding the session that can be significant for a therapist to process in their own therapy. It’s necessary for therapists to pay close attention to any transference and/or countertransference that may be present in the therapy room.
• Follow-up questions about a small detail that a client shared, so the therapist doesn’t forget to ask in future sessions.
• Speculations on future therapy themes or treatment directions.

They do not include:

• Medication logs, prescriptions, and monitoring a client’s reactions to medication.
• Session start and stop times, for insurance purposes or general billing.
• Frequency of treatment, upcoming sessions, or recommended cadence of therapy.
• The results of clinical tests.
• Summaries of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date.

These exclusions are necessary to maintain the personal and confidential nature of psychotherapy notes. There are also several details listed that should be noted elsewhere and included in the client’s official medical record instead.

Understanding what is part of the psychotherapy note, as well as what isn’t, is critical for utilizing these notes effectively.

HIPAA and psychotherapy notes

Under the Health Insurance Portability and Accountability Act (HIPAA), psychotherapy notes receive special protection due to their sensitive nature. Therefore, the therapist and client are afforded greater privacy protections, compared to medical records.

You may be wondering, When can psychotherapy notes be disclosed?

In order for them to be disclosed, it would generally require the client’s explicit authorization, except in specific circumstances such as legal obligations—like in the rare instance they’re specifically court ordered and subpoenaed by a judge.

It’s important to note that psychotherapy notes are distinct from other health information, and, therefore, they are not included in the client’s general medical record. This distinction underscores the importance of maintaining their confidentiality.

Best practices

When documenting psychotherapy notes, consider the following best practices:

• Separate storage: Keep them separate from the client’s medical record to ensure confidentiality. It’s important to note, some electronic health records (EHRs), such as SimplePractice, offer the ability to keep your psychotherapy notes in the EHR but in a separate field so they’re not to be mistaken for progress notes, or other parts of the client’s records. This can be a nice alternative to keeping track of physical notes.
• Be clear and concise: Use clear and concise language to accurately reflect the session’s content. When writing, pretend a judge or your client will see what you are writing—even if this is unlikely.
• Secure storage: Ensure that notes are stored securely, whether in physical or electronic form, to prevent unauthorized access.
• Regular review: Periodically review notes to ensure they remain relevant and necessary for ongoing therapy. Again, the purpose of these notes is to support continuity of care, so reviewing these notes should be a helpful part of tracking your treatment progress and mapping out a path for your client’s ongoing therapy.

Adhering to these practices enhances the therapeutic process, and also ensures compliance with legal and ethical standards. Both are critical for a therapist, along with ongoing support.

Examples of psychotherapy notes

In reviewing our examples of psychotherapy notes, it’s important to consider how you would integrate psychotherapy notes into your practice, where you’ll be writing them, and what purpose they’ll serve.

These examples of psychotherapy notes may not be perfectly suited for your practice, but they can be a starting point for you to think about the psychotherapy notes format you’ll use.

While psychotherapy notes are highly individualized and typically take the form of short bulleted lists scribbled in a notebook, there are electronic health records (EHRs) that include psychotherapy software—like SimplePractice.

Here are some general examples of psychotherapy notes that you may include in a designated section of your EHR or on a notepad separate from your progress notes:

• Client A: “Discussed recurring dreams involving water. Client appeared anxious when recounting these dreams. Dreams may relate to unresolved trauma from childhood.”

• Client B: “Client expressed frustration with their work situation and using communication skills effectively with husband. Avoiding confrontation with Dad, fear of abandonment? Connect with the client’s inner-child next session, circle back.”

These examples of psychotherapy notes illustrate how therapists might document their impressions and plans for future sessions.

Remember, the primary purpose of a psychotherapy note is to ensure continuity of care for clients by means of supporting a therapist’s memory. The above examples of psychotherapy notes will be helpful in navigating this process.

Conclusion

In private practice, maintaining accurate and confidential psychotherapy notes is a cornerstone of effective and ethical client care.

By understanding the purpose, content, and legal frameworks governing psychotherapy notes, therapists can enhance their practices and uphold the trust of their clients.

The reality is that we, as therapists in private practice, wear so many hats—ranging from business management to clinical care.

I’ve had supervisors who encouraged me not to keep psychotherapy notes for a myriad of reasons.

However, if we are aware of and fully understand the limitations, risks, and ethics, psychotherapy notes can be a helpful tool to  support yourself as you provide care.

How SimplePractice streamlines running your practice

SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.

If you’ve been considering switching to an EHR system, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.

Try SimplePractice free for 30 days. No credit card required.