Psychotherapy Notes vs. Progress Notes: What should you use? | Carepatron

What's the difference between progress notes and psychotherapy notes? What do HIPAA regulations require from you? And as a mental health professional who wants to demonstrate best practices, which progress note format should you be using? 

These are some of the questions a new mental health clinician might be asking, and for good reason. It can be hard to know how to go about daily tasks when entering mental health and why more experienced practitioners may demonstrate differing methods.

Not to worry! In this article, we'll explain psychotherapy notes and progress notes and give mental health professionals like you some insight into what your note of choice should be. 

What are progress notes?

Progress notes are an integral part of any client's medical records. You'll need to keep them to remain compliant with the Health Insurance Portability and Accountability Act (HIPAA) and on track with your client's journey. Progress and therapy notes include the medical history, treatment plans and frequency of therapy sessions, medication information, symptoms, progress, and plan. A progress note often follows a standardized template such as SOAP, DAP, or DARP frameworks.

Mental health progress notes are vital as they act as a way of communication between the behavioral health professionals, medical examiner, and the client and help the clinical therapist keep track of the client's progress. Additionally, they provide a legal record of any interaction between client and practitioner. In short, not only are progress notes very helpful, but they're a legal requirement, too. This is included in a client's electronic health record and further highlights keeping progress notes secure as this is protected health information.

Check out some excellent progress note examples here. 

What are psychotherapy notes?

Psychotherapy notes are created solely to help the practitioner who created them remember the therapy discussion or session content. Think of them as private notes or the therapist's personal notes. They are not intended to communicate or even be seen by anyone else.

A psychotherapy note is kept separately by a mental health professional, documenting information about a client's therapeutic journey. It is granted special protection under HIPAA as it likely contains an individual's medical record and particularly sensitive information and is not created to be reviewed. 

Psychotherapy notes exclude: 

• Medication prescription and monitoring
• Counseling session timelines 
• Modalities and frequencies of treatment 
• Results of clinical tests
• This is a summary of the diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date.

Progress notes vs. psychotherapy notes: A direct comparison

Despite sounding similar and having a seemingly similar purpose, psychotherapy notes, and progress notes are very different. The main reason is that psychotherapy notes are not made to be seen by anyone other than the person who made them. To make the differences easier to understand, we've created a chart to summarize. 

Psychotherapy notes taken during a private counseling session or a family counseling session are given far more protection concerning disclosures. Still, it is essential to remember that no record or process notes are ever fully immune from exposure. Hence, a general warning to remain professional and never include anything in a client's history will do more harm than good. This is especially essential when mental health professionals diagnose a client, as confidentiality and legal compliance are both considered.

Check out this page if you want some more info on disclosure.  

Which types of notes should a mental health professional use?

In short, use progress notes. Why? 

There are plenty of reasons to keep progress notes. These are just some of them; 

• Progress notes are a contract between the client and their clinician. They are where treatment goals and plans can be discussed and decided on before they are put into a document to track the treatment progression. 
• Progress notes provide a means of communication within and between care teams. They enable healthcare workers who provide care for the same client to know what occurred in the last session or acute episode, allowing them to provide the most appropriate and accurate treatment for their presenting issue. 
• As healthcare professionals, remembering details about every session can take a tremendous toll on your mental load, no matter how good your memory is. Writing them down provides an important reference point for you and ensures you can build rapport with each client by remembering essential details about each session. 
• Progress and clinical notes are legal documents, and you are required by law to keep a record of each client's care history for regulatory, insurance, and legal purposes. 
• When making notes based on a psychotherapy note template, you should be able to include all required information. Therefore, creating psychotherapy notes means you'll be doubling up on the documentation process tasks. 

Progress note-taking tips

1. If you don't have to, do not keep psychotherapy notes.
2. If you feel that you must keep these notes recorded: 

• Do not put anything into your client's record that can do more harm than good.
• Proactively address possible challenges you might encounter when writing these notes.
• Utilize general as opposed to specific language whenever possible 
• Avoid the use of direct quotations.
• Exclude interpersonal stress, family conflict, painful memories, distressing recollections of past events, affect regulation, and guilt/regret over past behavior.

Still want more information? Check out this document.

Best practices for taking progress notes and psychotherapy notes

As we don't recommend keeping psychotherapy notes, we've put together some tips and pointers to ensure your progress notes are up to professional standards:

• Be specific and concise in your progress notes. No one in the healthcare sector has time to write or read novels. 
• Prioritize your notes; letting them build up will only make the job seem more unachievable. 
• Capture and store your progress notes on a secure practice management platform.
• Utilize efficient templates such as SOAP notes 

But wait, what are SOAP notes?

SOAP is an acronym that stands for subjective, objective, assessment, and plan. This provides a healthcare provider with a more structured approach to taking progress notes. The elements of an efficient SOAP note are:

• S: Focused on the client's experience and perceptions of symptoms, needs, and progress toward treatment goals.
• O: Includes observable, objective data ("facts") regarding the client, such as elements of a mental status exam or other screening tools, historical information, medications prescribed, X-ray results, or vital signs.
•  A: Includes the clinician's assessment of the available subjective and objective information. The assessment summarizes the client's status and progress toward treatment plan goals.
•  P: Record the actions to be taken based on the clinician's assessment of the member's current status, such as assessments, follow‐up activities, referrals, and changes in treatment. 

Whether you decide to use progress notes or psychotherapy notes in your future sessions, it's important to consider what would benefit you as a healthcare professional in delivering quality care. You can also turn to helpful software solutions such as Carepatron. We have designed reliable clinical notes software for healthcare providers to manage documentation and electronic patient records securely, with an extensive library of psychology resources.