Psychotherapy notes are a necessary part of being a therapist. They’re different from progress notes because you don’t record them for others to see. Unlike progress notes, which are meant to be shared with other members of the treatment team, psychotherapy notes are just for your eyes.
So what are psychotherapy notes? Where were you supposed to learn how to use psychotherapy notes? Well, psychotherapy notes are the notes a therapist takes about the client, usually in session, documenting or analyzing the contents of the conversation. They inform the client’s treatment. They also inform diagnosis. But, psychotherapy notes are different from progress notes and are not part of the client’s clinical record.
It’s important to know how to take good psychotherapy notes while sticking to HIPAA rules and regulations. Remember, your clients should only see their progress notes if you feel it’s appropriate, while psychotherapy notes shouldn’t be shared with anyone else. Psychotherapy notes are just for your use. They might inform the progress notes you submit to the insurance company, record in the client’s clinical chart, or share with the treatment team, but they aren’t the same thing.
What Are Psychotherapy Notes?
Let’s dive a little further into what psychotherapy notes are. Psychotherapy notes help determine a treatment plan. They also help inform a diagnosis that a therapist makes. Psychotherapy notes include:
Insight into Treatment Plan: Psychotherapy notes serve as a valuable tool in shaping and refining a client's treatment plan. By documenting your thoughts, assessments, and observations during sessions, you can develop a comprehensive strategy to address the client's needs and goals effectively. This allows you to tailor interventions and techniques that are specifically suited to the client's unique situation.
Informed Diagnosis: Accurate diagnosis is crucial in providing effective mental health care. Psychotherapy notes play a role in supporting diagnostic processes by capturing your thoughts or hypotheses about a client's diagnosis. These notes can help you track the presence of specific symptoms over time, contributing to a more precise and informed diagnosis.
Session Observations: Recording your observations of the client during sessions provides a comprehensive understanding of their verbal and nonverbal cues, body language, emotions, and reactions. These observations can be critical in identifying patterns, triggers, and progress, helping you adjust your therapeutic approach accordingly.
Personal Reactions and Feelings: Acknowledging your personal reactions and feelings about a client's situation is an essential aspect of the therapeutic process. Documenting these reactions helps you remain aware of potential transference (projecting your feelings onto the client) or countertransference (projecting the client's feelings onto yourself), ensuring that these dynamics are managed ethically and effectively.
Transference and Countertransference: Psychotherapy notes can provide insights into the transference and countertransference dynamics occurring within the therapeutic relationship. These dynamics offer valuable clues about underlying issues, unresolved conflicts, and the client's emotional responses to different situations.
Supervision and Consultation: Keeping a record of questions you want to discuss with your supervisors or peers during supervision sessions is crucial for your professional growth. Sharing your thoughts and uncertainties fosters a collaborative learning environment and ensures that you receive guidance on challenging cases.
Session-Related Tasks: In addition to capturing session content, psychotherapy notes can help you stay organized by documenting any follow-up tasks you plan to address before the next session. This might include research you need to conduct, materials you want to provide, or interventions you intend to implement.
Legal and Ethical Considerations: Psychotherapy notes are subject to legal and ethical guidelines. It's important to maintain their confidentiality and ensure that they are securely stored. While progress notes, which contain summaries of session content, may be shared with clients' consent or as required, psychotherapy notes are generally more protected due to their personal and often exploratory nature.
Evidence-Based Practice: Comprehensive and accurate psychotherapy notes contribute to evidence-based practice. Documenting your rationale for interventions, tracking progress, and noting changes over time helps build a solid foundation for evaluating the effectiveness of the therapeutic approach you're using.
Client Empowerment: Sharing insights and observations from psychotherapy notes with your clients, when appropriate and with their consent, can empower them by providing an opportunity for collaborative goal-setting, self-awareness, and understanding of their therapeutic journey.
Psychotherapy notes can help you focus on the treatment goals, reflect on the session, and help prepare you for the next session. You might discover something important during a session. If you document it in your psychotherapy notes you can refer back to it the next time you meet with the client, without it being a part of the client’s clinical record.
Psychotherapy notes are helpful in reflecting on the time you spent with your client. Some therapists call psychotherapy “session notes” or “process notes.” This is fine, as long as you remember that they’re different from progress notes and don’t get submitted to insurance, integrated into the client’s clinical record or shared with a treatment team.
When organizing your session or psychotherapy notes you should make sure each client has their own file. You can write and store your notes digitally or by hand. Some therapists like to use legal pads, others have notebooks or forms that they use to fill out their session notes to reduce the amount of time spent on each note. Remember, if you’re writing a psychotherapy note on each of your clients, you want it to be effective but efficient. You only have so much time to write notes – don’t spend it reinventing the wheel every time.
Additionally, psychotherapy notes are required to be kept separate and distinct from the client’s clinical or medical chart. Some therapists keep an electronic health record from their progress notes, while they keep a physical notebook for their psychotherapy notes. Other therapists digitally store both progress and psychotherapy notes, but each type of note is saved in a separate and distinct document.
However you do it, you must keep psychotherapy notes separate. If you keep your psychotherapy notes separated from the client’s clinical or medical records, then your psychotherapy notes cannot be subpoenaed by insurance companies or the court of law.
How Are Psychotherapy Notes Different From Progress Notes?
Progress notes are different from psychotherapy notes, although they’re just as important. Progress notes are written after every session and added to the client’s clinical record. Progress notes are required documentation of the service you provided to the client and may be requested by insurance companies, treatment teams, or the client themselves. In contrast, psychotherapy notes are a therapist’s notes taken during a session that are meant just for the therapist’s eyes.
Psychotherapy notes, also known as process or private notes, include a therapist’s hypothesis about a diagnosis. They also could include observations made during the session as well as thoughts and feelings related to the client that the therapist notices. Psychotherapy notes typically contain more sensitive information that the therapist is working though before appropriately synthesizing it into a progress note, and thus, the client’s clinical record.
Psychotherapy notes inform treatment for your own process while progress notes make observations about the client in a session. Included in progress notes are the client’s affect, their treatment areas, objectives, the focus of the session, interventions used during the session, and anything of note that the client said that relates to their treatment process. These notes are meant to help the treatment team and the insurance companies see the progress the client is making in their treatment through objective data.
Psychotherapy notes aren’t part of medical records or billing information, unlike progress notes. Psychotherapy notes should be stored in a separate location from the client’s clinical or medical record. If your psychotherapy notes are integrated into the client’s medical record, the argument could be made that they are part of the progress notes. You should store and protect psychotherapy notes to the same confidentiality standard of the client’s progress notes.
How to Use Psychotherapy Notes
As we mentioned before, psychotherapy notes are best used for sensitive information that you’d rather not be included in the client’s medical or clinical record, such as observations, thoughts, reflections, feelings toward the client’s situation, and a hypothesis of diagnosis. Nothing is off-limits in your psychotherapy notes. You may not have learned in graduate school how to use psychotherapy notes, depending on what program you attended. Not all graduate programs cover how to use psychotherapy notes, although hopefully, you learned how to practically use psychotherapy notes during your hands-on clinical experiences, like an internship.
Because psychotherapy notes are different from progress notes, you need to know how to use psychotherapy notes in your client work. Progress notes are shared not only with the treatment team and the insurance company but also with the client themselves and family members with your client’s permission. In contrast, psychotherapy notes are meant for your eyes online, with the only exception being if the client asks to see them and you deem it appropriate. Sometimes sharing your thoughts about the client in your notes is useful for treatment progress, but in other situations, sharing your sensitive notes can do more harm than good. It is up to you to use your clinical judgment to determine what and when to share with your individual clients.
Examples of what to write in psychotherapy notes:
Behavioral Observations: Detailed descriptions of the client's appearance, behavior, and any notable changes can offer insights into their emotional state and progress. For instance, if the client arrives consistently late to sessions, noting this behavior can be a starting point to explore potential underlying reasons.
Hypotheses and Insights: Documenting your hypotheses about the client's experiences, thoughts, or motivations can guide your treatment approach. For example, if you suspect that a client's avoidance of certain topics is linked to a fear of vulnerability, noting this can help you tailor your interventions to address this issue.
Unfinished Conversations: Jotting down questions you didn't have time to explore during a session can ensure that you follow up in subsequent sessions. This practice maintains continuity and demonstrates your commitment to addressing the client's concerns comprehensively.
Therapist's Reflections: Recording your own thoughts and feelings during sessions provides a valuable self-awareness tool. Documenting your reactions to what the client is saying, as well as your emotions and responses to their disclosures, can help you recognize potential countertransference dynamics.
Countertransference Exploration: Elaborating on your own countertransference experiences—emotions and reactions triggered by the client's content—can offer insights into the therapeutic relationship. For example, if a client's anger makes you uncomfortable, noting this can prompt exploration into why this reaction arises.
Research and Homework: If you plan to provide the client with specific resources or suggest research materials related to their concerns, document these intentions in your notes. This ensures that you follow through on providing helpful information and educational materials.
Homework Assignments: If you assign homework or tasks to the client as part of their treatment plan, note these assignments in the psychotherapy notes. This way, you can track progress, evaluate the client's engagement, and discuss their experiences with the assignments in subsequent sessions.
Interventions Used: Document the therapeutic techniques or interventions you employed during the session. This can help you assess the effectiveness of different approaches and tailor your strategies to the client's responses.
Emerging Themes and Patterns: Identify recurring themes or patterns in the client's discussions across sessions. Noting these patterns can guide your exploration of underlying issues and assist in developing treatment goals.
Progress and Setbacks: Track the client's progress over time. Document improvements, setbacks, challenges, and successes to evaluate the efficacy of the treatment plan and make necessary adjustments.
Cultural Considerations: If the client's cultural background or identity is relevant to the therapy, make notes about how these factors influence their experiences and interactions within the therapeutic process.
Goals and Collaborative Planning: Summarize the goals discussed with the client during the session and any collaborative decisions made about the treatment direction. This helps maintain transparency and accountability.
Taking psychotherapy notes in session does not have to be distracting to the process. Although it might intimidate your client or make them wonder what you’re writing, using psychotherapy notes to keep your thoughts, questions, and observations in order can be critical to the therapeutic process. For example, you might write down things your client said that you want to revisit in a later session. Or perhaps your client is in the middle of a story and you want to make sure you ask a clarifying question about a statement they said earlier. Whatever the reason for your psychotherapy notes, you have to find the right balance between writing psychotherapy notes and listening during a session.
If you do take psychotherapy notes during a session, try to avoid using a computer. It can be the most distracting way to take notes while your client is sharing their experiences with you. If all they see is you looking at your computer and all they hear is the clack-clack-clacking of your fingers typing on the keyboard, they might feel as if your full attention isn’t on them and be less likely to open up in the therapy room. A sense of safety and trust is more difficult to establish and maintain when a therapist is using a computer in session. Additionally, your client does not know what is on your computer screen. While you might be simply taking notes in a blank document, they might be imagining you scrolling through Facebook or replying to emails during the session. This also goes for online therapy too. Try to limit your mouse and keyboard use in an online session to the very end or beginning, unless otherwise warranted.
Most psychotherapy notes are only interpretable to the clinician writing them, not by virtue of privacy or security, but rather because of clinician handwriting, acronyms, and symbols. If you’re trying psychotherapy notes for the first time, try to make a few notes with shorthand and symbols during the session Afterward, you can take 5-10 minutes to use your psychotherapy notes to write your clinical progress notes to be entered into the client’s clinical file. Your client may ask to see your psychotherapy notes. You aren’t required to show them, but it might help your client both trust you more and feel part of the process. If they see what you’ve written about their sessions they can get a better idea of what you’re working on with them. You should use discretion when sharing psychotherapy notes with a client, however, because they’re not as objective and full of just data as progress notes.
We hoped this answered your question “what are psychotherapy notes?” If you’re struggling with learning how to use psychotherapy notes, we’re here to help. The Therapist Network provides an opportunity to make connections with other therapists who are experienced in writing psychotherapy notes, along with many other specialties. Join the Network to build relationships with other therapists and enjoy unlimited clinical consultation groups. You don’t have to do it alone!
