Therapy Notes

Progress and psychotherapy notes serve different purposes. Psychotherapy notes act as a personal record for therapists. Progress notes are the documentation of medical records. From the California Association of Marriage and Family Therapists, staff attorney Michael Griffin shares more on writing progress notes, including how therapists must legally and ethically maintain a record of the treatment they provide.

Think of progress notes as the common thread between your patient’s healthcare providers. A client usually sees multiple healthcare professionals like a general practitioner, mental health therapist, and psychiatrist. It’s important to create a record of documentation that keeps everyone in the loop on the patient’s treatment.

Progress notes are a form of medical documentation
written and accessible by all the patient’s healthcare providers. 

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Progress notes focus on treatment and assessment plans,
medical information, clinical test results, and diagnoses.

Psychotherapy notes are helpful between sessions for the therapist to document and recall notable parts of their conversation with a client. They include details that stand out to the therapist, but are not necessary to include in the patient’s medical records if they are not required as part of the treatment plan.

Psychotherapy notes are written by a mental health professional documenting conversations separate from the patient’s medical record.

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Psychotherapy notes do not include information kept in a patient’s medical record.

Dr. Alina Kurland from Peninsula Behavioral Health, a private practice in the Bay Area, reveals her focus is on the client and she “might jot down a brief quote or a note about important data like mood, medication changes, or sleep.” A government-funded or nonprofit practice traditionally requires more notetaking and record keeping than private practices.

The HIPAA privacy rule protects a patient’s medical records and other personal health information. The U.S. Department of Health & Human Resources provides special protections to psychotherapy notes and sharing information related to mental health. Psychotherapy notes hold heightened protections because they contain particularly sensitive material that is generally only useful to the therapist. 

There are exceptions, like in cases of child abuse or imminent threats of danger, where therapists may need to disclose their psychotherapy notes or break confidentiality. Check the federal guidelines as well as case law within your jurisdiction of practice to understand if you are in a situation where you need to make a disclosure. 

In the forensic context, reports and affidavits are the primary ways psychologists present their notes in the courtroom, although in this context, notes are typically from an evaluation that is to address a specific legal question or issue (i.e., competence to stand trial). 

Practitioners who are called to testify in court about their interactions with a client in therapy are called as a witness of fact (as opposed to an expert witness) and will be required to disclose information contained in therapy notes. In this context, the practitioner is a fact witness and cannot give opinion testimony. Notes that document meeting dates and times as well as details about the meeting are helpful to practitioners in this context. 

Dr. Kukor Ph.D., a board-certified forensic psychologist, presents a new way to write forensic reports to help outline what you should and shouldn’t include in a forensic evaluation. A course with Dr. Otto Ph.D., another board-certified clinical and forensic psychologist, emphasizes the importance of conciseness and relevancy in your report writing for forensic evaluation. 

• AAFP: A New Way to Write Forensic Reports 
• Report Writing for Forensic Evaluation

There are plenty of formats available to choose from when taking therapy notes. Choose the note template that you feel is the best fit for your needs. Overall, most therapy notes follow a general format which includes a client or patient’s progress, symptoms, assessment, and treatment plan.

S.O.A.P.

Subjective: The subjective section includes the patient’s concerns, feelings, and history of illness. 

Objective: The objective components are interventions the health care provider can chart during the session, like psychological status and affect. 

Assessment: The assessment is where the healthcare professional provides a diagnosis. 

Plan: The plan is the documentation of treatment moving forward. 

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Initially created to organize medical records, the S.O.A.P note template is widely recognized in healthcare. Purdue’s Writing Lab advises avoiding confusing pronouns and overly wordy or biased phrasing in their S.O.A.P. note tips. 

Try to stick with specific, concise, and non-judgemental notes. Dr. Kurland, who works with evidence-based therapy at a trauma-focused clinic, says she tends to use the S.O.A.P format.

B.I.R.P.

Behavior: Create behavioral notes from the patient’s statements and the therapist’s observations. 

Intervention: The intervention focuses on what methods it takes to reach a patient’s goal or objective. 

Response: The response is where the therapist records how the patient reacts to interventions. 

Plan: The plan outlines the next steps in the treatment progress. 

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Alameda County Behavioral Health Care Services offers an in-depth B.I.R.P progress note checklist. Keep in mind to write notes so that any healthcare provider that accesses them understands what happens during treatment. 

D.A.P.

Data: Documentable data refers to the behavior, thoughts, and feelings expressed throughout a session. 

Assessment: The assessment is the mental healthcare provider’s professional diagnosis and the patient’s progress. 

Plan: The plan documents plans and treatment moving forward. 

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The Substance Abuse and Mental Health Services Administration shares a D.A.P progress note checklist with a comprehensive questionnaire guide. 

There are plenty of mental health apps and therapy note softwares to choose from, so it helps to look at what practicing professionals are using. Dr. Kurland shares that her private practice uses SimplePractice, a HIPAA compliant EHR software. 

Consider a course on the foundations in digital therapy to learn more about mental health apps and internet intervention programs with Dr. C. Barr Taylor MD, a Stanford psychiatry professor and Palo Alto University research professor. Or, examine the growing rates of online psychological interventions like websites, mobile applications, and other digital tools with Dr. Muñoz Ph.D, a bilingual clinical psychologist and current Palo Alto University distinguished professor. 

• Foundations in Digital Therapy 
• Evidence-Based Internet Interventions to Reduce Health Disparities