Psychotherapy Notes vs. Progress Notes
Good record-keeping is a crucial part of mental health practice. Records benefit your clients by documenting their medical history and care across time. They also help you to plan, record and monitor treatment, and protect you from liability in the event of an alleged breach of your legal or ethical requirements.
Psychotherapy Note & Progress Note Definition
Two main types of records exist across mental health practice. You may keep basic records, or progress notes, detailing your client’s clinical status and achievements during hospitalization or outpatient care. Progress notes are considered part of the client’s record or file. Progress notes usually follow a standardized format, such as SOAP (Subjective, Objective, Assessment, and Plan) and include details of your client’s symptoms, assessment, diagnosis, and treatment. While guidelines may differ slightly when writing social work notes versus counseling notes or counseling progress notes, all will allow you to compare your client’s past and current statuses, communicate your findings and allow a retrospective review of case details.
For years, therapists have debated about whether it was permissible to maintain a separate set of notes that were only available to the therapist. This meant that, in addition to progress notes, you may keep another set of notes called psychotherapy notes. These psychotherapy notes document the conversations you have with your client, separately from your progress notes. They can be written in any form that is useful to you and need not be readable by others.
With the implementation of HIPAA, psychotherapy notes were given a clearer definition and earned some protections that shielded them from the normal release of health documents to clients or anyone else. The protections are important enough to warrant familiar with what psychotherapy notes are and what protections they have under the law.
Psychotherapy Note Formats Under HIPAA
Psychotherapy notes are defined under HIPAA as notes recorded in any medium by a mental health professional and include the documenting or analyzing the contents of conversations during a private counseling session, or a group, joint or family counseling session that are separate from the rest of the individual’s medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session starts and stop times, treatment frequency and modality, clinical test results and any summary of the following items: Diagnosis, functional status, treatment plans, symptoms, prognosis, and progress notes to date.
No styles are defined and no format is speculated in practice. You simply make sure to exclude items that may lead to your psychotherapy notes being defined as a typical progress note, which generally contains the items mentioned earlier.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes minimum provisions for the use and disclosure of your progress and psychotherapy notes. However, if state law provides greater protection for your client than HIPAA, the state law must take precedence over HIPAA.
Your psychotherapy notes receive special protection under the HIPAA due to the high likelihood that they contain especially sensitive information, and also because they are your personal notes—intended to help you recall the details of therapy sessions—and are of little or no use to others.
Privacy Rule Provisions
Under HIPAA’s Privacy Rule, you are obliged to protect your psychotherapy notes from view by unauthorized persons by keeping them physically separate from your progress notes. If you fail to do so, others may be able to access your psychotherapy notes without obtaining specific authorization from your client.
You cannot disclose your psychotherapy notes to others without your client first signing a detailed authorized form specifically for the release of these notes. By contrast, you could, in most states, release your progress notes to those involved in the provision of healthcare and any associated administration, billing and auditing tasks without consent, or following obtainment of your client’s signature on a generalized consent form. There may, however, be instances where you have to release your psychotherapy notes by law, or in compliance with administrative requests from government agencies.
The Privacy Rule safeguards your psychotherapy notes by not only giving important rights to your clients but also to you as the treating practitioner. Although your clients have a right to view most of the health information held about them, including your progress notes, they do not have a right to inspect your psychotherapy notes. Therefore, you do not have to fulfill client requests for access to these notes.
Security Rule Provisions
If you store your notes electronically, for example, in practice management software that allows for electronic medical record (EMR) creation and storage, HIPAA’s Security Rule requires you to guard against the unintended disclosure or destruction of these notes. You must, therefore, put appropriate administrative, physical and technical safeguards in place to ensure the confidentiality, integrity, and security of your notes. You must also keep your electronic psychotherapy notes separate from your electronic progress notes to ensure that your psychotherapy notes remain off-limits to others.
One way to your fulfill obligations under the HIPAA is by implementing specialist psychotherapy notes software. If you use psychotherapy note software, you will benefit from primers and other tools that ensure you have the measures in place to protect your notes and avoid costly regulatory enforcement.
Software That Has Your Back
TheraNest’s HIPAA-compliant software is designed to help you create, store and manage your counseling progress notes while complying with HIPAA’s Privacy and Security Rules. TheraNest offers multiple daily encrypted backups using bank-level SSL certificates, ensuring that your notes cannot be easily accessed or understood by unauthorized individuals.
There’s nothing like feeling secure, especially when your practice is at stake. Let us handle the stress of HIPAA security for you, and test a 21-day free trial of TheraNest’s therapy note software, no credit card information required.