What Are Psychotherapy Notes?

Under HIPAA, process notes (or “psychotherapy notes”) are more strictly regulated than any other client records. Psychotherapy notes are those notes you take during a session with your client, for your own safekeeping. Think of them as cliff notes of the very personal and confidential conversations you have with your client, only meant to be read by yourself. These notes may include:
 

1. Observations: Details about a client's appearance, behavior, body language, and mood. For example, you might write that the client arrived 15 minutes late to the session and slouched in the chair.
2. Analysis and hypotheses: Information about the patient’s background and experiences that inform a diagnosis. For example, a psychotherapy note might explore how a client’s aversion to leaving the house is linked to an earlier traumatic experience.
3. Questions to ask supervisors and colleagues.
4. Personal reflections regarding the therapy session.
    

PLEASE NOTE

While you may refer to your psychotherapy notes when determining an effective treatment plan or writing SOAP notes, you should be sure to keep psychotherapy notes outside of a client’s official medical record. Medical records may be requested by payers for billing purposes or other providers for treatment purposes. Commingling psychotherapy notes with medical records would result in the inadvertent disclosure of highly confidential and sensitive information that should only be viewed by yourself. Therefore, it is recommended to keep these records separate at all times. 
 

Please review the resources below for more information 

Additional Resources

• How to Write SOAP Notes
• Does HIPAA provide extra protections for mental health information compared with other health information?
• HIPAA's Privacy and Security Rules
• Protected Health Information Disclosure Authorization Template