When I’m providing consultations, therapists constantly tell me:

The use of the phrase “my notes” often reflects a common but outdated concept: The idea that session notes are the clinician’s.  However, the modern view of notes has significantly shifted to view the chart as the client’s medical record, not the clinician’s. (This may seem obvious, but read on…)  The shift was codified in 2000, when HIPAA Privacy Rules gave clients the right to view and receive a copy of their medical records, and to have a copy transmitted to a designated person. Clients were also given the right to view all billing and payment records in their chart. (For more on HIPAA and clients’ rights, click here).

“Barbara, I know the notes aren’t really ‘mine.’ So, what’s your point?”  My point is on a daily basis it is easy to forget that notes belong to the client, so we often let bad habits develop, such as falling behind in writing notes, writing superficial notes, and writing notes no one else can read. It’s important to remember that:

1)  In most situations, our job may be to assist a client in making an informed choice about the release of notes — not to make the decision ourselves.  I’ve had situations where the client was fine with the release, when I wasn’t keen on it.  Their notes, their decision.

2) You must write good notes. You have the legal responsibility to keep a medical record and to write good notes for each session. This includes detailed and legible payment and billing records. “Having a good memory” does not fulfill this duty.

3) Believe me, I know how hard it is to keep up with notes, but it has to be a priority. Insurance plans are asking for records more frequently than in the past, and you must always be prepared to turn them over to a licensing board, ethics committee, to a client, or for a disability review. You can’t just rewrite (or write) notes if faced with a record request. It is fraud to misrepresent the date that a note was written, and fraud is a crime.

4) You must write notes as if your client (or someone else) will read them, so they must be readable to others.  Be objective. Avoid negative characterizations.

5) You might explore ways to “open” notes as part of treatment.  I have found reading notes to clients to be a powerful tool to help them recognize progress. In listening to what i have written, it also validates that I really hear them.

“But what about HIPAA-defined ‘psychotherapy notes?'”  Great question.  First, let’s define psychotherapy notes.  HIPAA defined psychotherapy notes as optional notes clinicians may keep with their personal analysis of sessions.  They must be kept separate from the client’s chart.  Psychotherapy notes cannot include factual details that belong in the medical record, such as session start/stop times, modalities and frequencies of treatment, test results, medication, diagnosis, functional status, treatment plan, symptoms, prognosis, and progress.  Under HIPAA, psychotherapy notes are afforded a higher level of confidentiality than session notes, so clients — and insurance plans — can’t view them.  But don’t be fooled into thinking these are completely confidential; they can be subpoenaed, and the client can authorize their release to others. That’s why I join many attorneys in discouraging therapists from keeping them. (click here or click here for more info about psychotherapy notes and HIPAA).

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