Progress Notes vs. Psychotherapy Notes: Do YOU Know the Difference?
By Barbara Griswold, LMFT (June 5, 2017)
When coaching therapists about what should be in their client charts, I find they often mistakenly use the terms “progress notes” and “psychotherapy notes” interchangeably. However, there are important differences.
PROGRESS NOTES: Progress notes are part of the client’s medical record and reflect what has occurred in treatment. They may include assessment and diagnosis, treatment modality and frequency, session start/stop times, topics discussed, interventions, medication monitoring, test results, summaries of functioning, symptoms, prognosis, and progress, treatment plan, and observations/clinical assessment of the client in session.
Since progress notes are part of the medical record, and because clients typically have the right to inspect them, they must be readable by others. There is no mandated format, but state law and professional ethics may address what the notes must include, and insurance plans will typically have a list of what they require in these notes (to be sure your records meet all documentation requirements, check out my Progress Notes Webinar).
PSYCHOTHERAPY NOTES: “Psychotherapy Notes” is a term coined by HIPAA. These additional notes, commonly referred to as “process notes” or “private notes,” ARE NOT REQUIRED. But should you choose to keep them, HIPAA affords extra protection to them, if they remain separate from the client’s record. Insurance plans cannot require you to turn over psychotherapy notes in case of an audit or record request, and clients do not have the right to view them. It typically takes a legal action to compel their release.
So, what can be in these notes? According to HIPAA, psychotherapy notes are “notes recorded (in any medium) … documenting or analyzing the contents of conversation during a private counseling session…that are separated from the rest of the individual’s medical record.” Kind of vague, right? The idea was to allow extra protection for a therapist’s personal notes, such as thoughts and feelings about a case, theoretical analysis of sessions, or notes in prepare for consultation. You may record questions for future sessions, hunches, areas for further exploration, questions to bring up with a consultant, and feedback from consultation.
Since psychotherapy notes are not part of the official medical record, they can be in any form that is useful to you, and need not be readable by others (e.g. you may use your own abbreviations or shorthand). However, psychotherapy notes cannot take the place of progress notes, and are not a place to hide sensitive client private health information from the medical record. Psychotherapy notes MAY NOT include any of the information that belong in progress notes (as described above) that are part the medical record.