One of the most popular questions I get asked is, “What is the difference between Progress Notes and Psychotherapy Notes?” There is a lot written about this and I stumbled upon an article a while back that did a good job of explaining the difference between the two. Here are the highlights.
Progress notes establish the progress of treatment. This includes assessment, diagnosis, and treatment protocols, including documentation of how the clinician addressed crisis issues and processed them. Progress note content can be kept to a minimum because many of the functions of notes for the purposes of the treating clinician can be accomplished through psychotherapy notes.
The following kinds of information go in a progress note:
- Medication prescription and monitoring.
- Modalities and frequencies of treatment furnished.
- Results of clinical tests.
- Any summary of the following items: diagnosis, functional status, symptoms, prognosis, and progress to date.
The note may be brief but should include a description of the major events or topics discussed, specific interventions used, your observations and assessment of the client’s status, and any plans you may have for the future. It is not necessary that these notes be extensive. You can use structured formats such as DAP and SOAP, or you can use an unstructured format, it’s up to you.
Psychotherapy Notes (Process Notes): Not required
Psychotherapy or Process Notes are commonly referred to as Private Notes. Meaning companies cannot require you to turn over psychotherapy notes during an audit of your patient records. Patients do not have the right to inspect or obtain a copy of psychotherapy notes. However, it is important to mention that there are instances where you may be required to turn over your Psychotherapy Notes as required by law, or in compliance with any of the following:
- A court order or court-ordered warrant, subpoena or summons issued by a judicial officer.
- A grand jury subpoena.
- An administrative request from a government agency, including an administrative subpoena or summons, civil or authorized investigative demand or similar process authorized by law.
- Administrative requests, that meet the following condition: The information sought must be relevant to a legitimate law enforcement inquiry.
Psychotherapy notes are notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record.
Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
Psychotherapy notes can be in any form that is useful to you and need not be readable by others (e.g. use of your own personal shorthand is acceptable). Think of psychotherapy notes as a form of self-consultation and preparation for supervision. It is here that you may feel free to detail what occurred in a session in order to put your thoughts and feelings about what was going on, list hunches and hypotheses to explore further, and write questions to bring up with your supervisor. You may also want to jot notes from a supervisory session that you want to include in your thinking for future sessions.
HIPAA protects psychotherapy notes from the blanket release that allows medical information to be used for administrative purposes. It requires that the notes be protected from view by anyone other than the counselor and anyone to whom the records are specifically authorized for release. HIPAA protections for psychotherapy notes include the provision that they remain separate from the client’s main record.
I hope this article helps you understand the difference between the Progress Notes and Psychotherapy Notes.