Progress Notes vs. Psychotherapy Notes: Do YOU Know the Difference?
By Barbara Griswold, LMFT (February 6, 2022)
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” — as defined by the Health Information Portability and Accountability Act (HIPAA) — are a REQUIRED part of the client’s medical record and reflect what occurred in each visit. HIPAA states that 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.
Key points about progress notes:
- Progress notes are part of the client’s official medical record. You are simply the custodian of this record.
- They must be readable to others, since clients and their insurance plans have the right to inspect these notes, or even ask for a copy. Progress notes may also be reviewed in the event of a disability claim, legal case, and ethics or licensing board complaint.
- 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 learn the 11 things that insurance plans typically require in Intake Notes and Progress Notes, and 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. While commonly referred to as “process notes” or “private notes,” HIPAA defines psychotherapy notes as “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 afford extra protection for a therapist’s personal notes, such as thoughts and feelings about a case, personal impressions of a client, or theoretical analysis of sessions (e.g. transference, resistence, etc) that would not be appropriate as part of the client’s medical record. You may also record questions for future sessions, hunches and theories, areas for further exploration, and questions to bring up with a consultant. I think of them as kind of the therapist’s diary of the therapy.
A few important things to know about Psychotherapy Notes:
- Psychotherapy Notes ARE NOT REQUIRED.
- Should you choose to keep them, they MUST be kept separate from the client’s medical record (progress notes). Otherwise, they will not be afforded the higher higher level of privacy. By blending psychotherapy notes and progress notes you remove all added security, and even an insurance plan could get access to the complete blended records.
- According to the attorneys I have interviewed, you cannot hide sensitive or potentially embarrassing session information in the psychotherapy notes — for example, if a client is having an affair, or is HIV-positive. Topics like these that are a focus of treatment belong in the medical record — in a progress note, not a psychotherapy note (see progress note definition above).
- The good news: 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.
- The bad news: Psychotherapy notes are not completely confidential. A court can order them to be turned over, and in a complaint situation they might be requested. For this reason, many attorneys don’t recommend you keep psychotherapy notes. If you do, it is recommended you write them with the knowledge they could be released.
- Since psychotherapy notes are not part of the official medical record, they can be in any form that is useful to you.
Don’t have confidence in your Progress Notes? Check out my Progress Notes Webinar !