I’ve been getting a lot of questions from therapists about an important topic that begs to be addressed: How does the recent political climate affect our documentation and our clients’ privacy?

President Trump and legislatures nationwide are passing laws that have a negative impact on some of our clients. Undocumented immigrants are afraid of deportation and family separation.  Birthright citizenship is being questioned. Laws are denying transgender individuals’ rights and removing coverage for gender-affirming care. Other laws target the rights of LGBT individuals.  Laws across the country heavily restrict abortions, criminalize them, and even punish healthcare providers who discuss abortion options.

Whatever you personally think of these laws or this Administration, I’m hearing from therapists that they are being impacted, also.

Clinics and hospitals are facing a hard choice: Comply with these new rules and sometimes abandon clients, or risk the loss of desperately needed federal funding for treatment and research.

Additionally, clinicians are expressing concerns about access to client files.  The  Wall Street Journal reported that Elon Musk and his DOGE team now have access to all client files at Medicare and Medicaid to address fraud. In a recent post on X, Musk stated “Yeah, this is where the big money fraud is happening.”

Perhaps the good news is that Kiplinger reports that according to the Wall Street Journal, “no access has been given to databases that include identifiable personal health information of Medicare or Medicaid enrollees,” and that DOGE’s access is “read-only,” which means that DOGE affiliates cannot make changes to the systems.

However, many therapists express concern that client private health information may not remain confidential from government authorities.  In a surprisingly brief comment on their website, the Center for Medicare and Medicaid Services (CMS) simply stated they are collaborating with DOGE, looking for opportunities with “more effective and efficient use of resources in line with meeting the goals of President Trump” (to read the CMS comment, click here).

What does this mean for therapists?

We are all struggling to figure out what this means for our documentation of clients we are treating.  Here’s just a few things I’ve heard from therapists out there:

• “I have no idea of the intentions of this Administration, but I am very concerned for my marginalized clients and those who have diagnoses that are stigmatized”
• “I am taking a hard look at what diagnoses I’m using. I may need to be cautious about which I use, for my patient’s safety”
• “I am considering reducing my notes to outline medical necessity very briefly, maybe just two vague lines.”
• “I am considering pivoting to paper charting”
• “Perhaps we should talk with transgender clients about whether they feel safe having this in their charts and on claims going forward.”
• “I wonder if an Adjustment Disorder diagnosis such as F43.23 with Mixed Anxiety and Depression would work in a lot of cases. It is often technically true in many ways — that patients are having challenges adjusting to life as lived and this is what brings them into the consultation room.”
• “I plan to stop documenting demographics like birthplace, race or religion as well as fertility info. And to be as vague about romantic relationships as possible.”
• “If a client is discussing the possibility of an abortion, I’m just going to write that they are coming for ‘relationship issues.’”

Admittedly, some presidential mandates have been based on commendable goals, such as investigating fraud and waste.  But therapists express fear that cost-cutting will be prioritized over patient care.  It is hard to know if these anxieties are reasonable or overblown.

So, the question I am getting is, “what about our documentation?  Do you recommend changes in our session notes, to protect our clients?”

I wish I could give my usual clear recommendations that will reassure us all.  But I can’t.  We don’t know what these changes mean, or what the future will bring.  At this point, we are told government authorities don’t have access to our client’s private health information.  But it is understandable that clinicians may not trust that these confidentiality  boundaries will be (or are being) respected.  So, I will share a few quick thoughts:

• First, let’s not panic.  We may see no changes to the level of confidentiality of your client notes. However, taking time to calmly consider each of your clients and documentation in the wake of recent legislation may be prudent.
• You might want to especially consider what you write about clients in plans that receive federal funding or are subject to federal oversight, such as Medicare, Medicaid, Tricare, the VA, etc.
• If you work with transgender clients, you may want to consider whether to mention their transgender status in your notes or claims.
• If you work with undocumented immigrants or clients with visas, you may want to avoid documenting their legal status or visa status.
• If treating a LGBT client or couple, you might just use the word “partner” and/or the partner’s initial in your note, instead of identifying the gender of the partner.
• If you work with clients considering abortion, and you are in a state that restricts or forbids abortion, be careful what you details you write in notes about the client’s presenting issue and the advice you give.
• However, don’t get too vague, or too brief. Your notes still must reflect the client’s issues and the service you provided.  If the note is too vague or brief, the insurance plan might not pay because the note is too superficial, or doesn’t defend the medical necessity for treatment.  For example, if treating a client around an abortion decision, instead of saying something as vague as “discussed relationship issues,” you might say “discussed mental health issues related to pregnancy.”  Better yet, to defend medical necessity, tie it to your diagnosis: “Discussed anxiety [depression] related to pregnancy.”
• I’m not sure that. a switch to paper notes is necessary, as one person suggested, or that it would give added protection. This might be an action to take down the line, if you remain concerned after we learn more.
• Consult with other therapists who treat affected populations  and in these marginalized communities as you struggle with documenting and providing their care. We need to support each other during this difficult time.

Wish you had more confidence in your notes?  Listen to the new 2025 recording of Barbara’s course, “What’s Missing From Your Charts: Writing Great Notes” – click here for more info or to purchase