What's the difference between progress notes and psychotherapy notes? What do HIPAA regulations require from you? And as a mental health professional that wants to demonstrate best practices which note format should you be using?
These are some of the questions a new mental health practitioner might be asking, and for a good reason. It can be hard to know coming into mental health how to go about daily tasks and why more experienced practitioners may demonstrate differing methods.
Not to worry, in this article, we'll run you through what both psychotherapy notes and progress notes are and give you some insight into what your note of choice should be.
What are progress notes?
Progress notes are an integral part of any client's medical records; to remain HIPAA compliant, you'll need to keep them. Progress notes include the treatment modalities and frequency of treatment, medication info, symptoms, progress, and plan. Progress notes often follow a standardized template such as SOAP, DAP, or DARP. Mental health progress notes are vital as they act as a way of communication between the care team and client and for the practitioner to keep track of client progress. Additionally, they provide a legal record of any interaction between client and practitioner. In short, not only are progress notes super helpful, but they're a legal requirement too, so whether you like it or not, you'll be keeping progress notes for every client you see.
Check out some excellent progress note examples here.
What are psychotherapy notes?
Psychotherapy notes are created solely for one purpose: to provide the practitioner who created them with some help at remembering the therapy discussion or session content. Psychotherapy notes are not intended to communicate or even be seen by anyone else. Psychotherapy notes are kept separately by the practitioner for their purposes. They are granted special protection under HIPAA as they likely contain particularly sensitive information and are not created to be reviewed.
Psychotherapy notes exclude:
- Medication prescription and monitoring
- Counseling session timelines
- Modalities and frequencies of treatment
- Results of clinical testing
- Any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
Progress notes vs. psychotherapy notes- A direct comparison
Despite sounding similar and having a seemingly similar purpose, psychotherapy notes and progress notes are very different. The main reason is that psychotherapy notes are not made to be seen by anyone other than the person who made them. To make the differences easier to understand, we've created a chart to summarize.
Psychotherapy notes are given far more protection concerning disclosures. Still, it is essential to remember that no record is ever wholly immune from exposure. Hence, a general warning to remain professional and never include anything in a client's history will do more harm than good.
Check out this page if you want some more info on disclosure.
Which types of notes should your medical practice use?
In short, use progress notes.
There are plenty of reasons to keep progress notes; these are just some of them;
- Progress notes are a contract between the client and their clinician. They are where treatment goals and plans can be discussed and decided on before they are put into a document to track the treatment progression.
- Progress notes provide a means of communication within and between care teams. They enable healthcare workers who provide care for the same client to know what occurred in the last session or their last acute episode—allowing them to provide the most appropriate and accurate treatment for their presenting issue.
- As a healthcare professional, remembering details about every session can take a tremendous toll on your mental load, no matter how good your memory is. Writing them down provides an important reference point for you and ensures you can build rapport with each client by remembering essential details about each session.
- Progress notes are legal documents, and whether you like it or not, by law, you are required to keep a record of each client's care history for regulatory, insurance, and legal purposes.
- You should be able to include all required information into making psychotherapy notes redundant. Therefore creating psychotherapy notes means you'll be doubling up on the documentation process tasks.
- If you don't have to, do not keep psychotherapy notes.
- If you feel that you must:
- Do not put anything into your client's record that can do more harm than good.
- Utilize general as opposed to specific language whenever possible
- Avoid the use of direct quotations.
- Exclude interpersonal stress, family conflict, painful memories, distressing recollections of past events, affect regulation, and guilt/regret over past behavior.
Still, want more information?
Best practices for taking progress notes and psychotherapy notes
As we don't recommend keeping psychotherapy notes, we've put together some pointers to ensure your progress notes are up to scratch;
- Be specific and concise in your progress notes. No one has time to write or read novels in the healthcare sector.
- Prioritize your notes; letting them build up will only make the job seem more unachievable.
- Capture and store your progress notes on a secure practice management platform
- Utilize a template such as SOAP notes
But wait, what are SOAP notes?
SOAP is an acronym that stands for subjective, objective, assessment, and plan. The elements of a SOAP note are:
Subjective (S): Focused on the client's experience and perceptions of symptoms, needs, and progress toward treatment goals.
Objective (O): Includes observable, objective data ("facts") regarding the client, like elements of a mental status exam or other screening tools, historical information, medications prescribed, x-rays results, or vital signs.
Assessment (A): Includes the clinician's assessment of the available subjective and objective information. The assessment summarizes the client's status and progress toward treatment plan goals.
Plan (P): Records the actions to be taken due to the clinician's assessment of the member's current status, such as assessments, follow‐up activities, referrals, and changes in the treatment.