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

What's the difference between progress notes and psychotherapy notes? What do Health Insurance Portability and Accountability Act (HIPAA) regulations require from you? And as a mental health professional who wants to demonstrate best practices, which progress note format should you use? 

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

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

What are progress notes?

Progress notes are an integral part of any client's medical records. You need to keep them to remain compliant with 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 communicate information between the behavioral health professionals, the medical examiner, and the client. They also 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 mental health records and further highlights keeping progress notes secure as this is protected health information.

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
• Summary of the diagnosis, functional status, treatment plan, symptoms, prognosis, and progress.

Psychotherapy notes aim to aid the therapist in their practice rather than serve as formal documentation for medical records.

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.

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 HIPAA Privacy Rule if you want some more info on disclosure.  

Which types of notes should a mental health professional use?

In short, use progress notes. Why? 

Creating separate psychotherapy notes alongside regular progress notes is generally not recommended for several reasons. Psychotherapy notes, while protected under HIPAA with special privacy rules, can create unnecessary complications in documentation and potentially increase liability.

Furthermore, maintaining two separate sets of notes increases the chance of discrepancies and adds to the administrative burden without providing significant clinical benefit. Most importantly, all essential clinical information should be captured in your regular progress notes, making separate psychotherapy notes redundant.

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 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, healthcare operations, and legal purposes. 
• When making notes based on a psychotherapy note, you should be able to include all required information. Therefore, creating psychotherapy notes means you'll double up on the documentation process tasks. 

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 pile up will only make the job seem more unachievable. 
• Capture and store your progress notes on a secure practice management platform.
• Utilize Mental Health Progress Note Templates such as SOAP notes. 

But wait, what are SOAP notes?

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

• Subjective: Focused on the client's experience and perceptions of symptoms, needs, and progress toward treatment goals.
• Objective: 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.
•  Assessment: 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.
•  Plan: 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 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, with an extensive library of psychology resources.