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:
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