The Gillman HIPAA progress note is an efficient, and most importantly, HIPAA compliant progress note format. It was created by Dr. Peter Gillman in order to create a note format that follows HIPAA rules while also being easy to use.

Psychotherapy Notes vs. Progress Notes

To understand the value of the Gillman HIPAA progress note, it’s a good idea to understand how HIPAA treats clinical documentation. A Psychotherapy note, also known as a Process Note is used during a treatment session as a the private note of the clinician. These are almost absolutely private except under the following circumstances:

  • A court order or a subpoena
  • A lawful request from a government agency
  • A lawful request from a law enforcement agency

Other than those limited circumstances, psychotherapy notes remain private to the therapist. Even a patient can not obtain these notes.

A Progress Note on the other hand is a record of treatment; it’s a documentation of the diagnosis, medications, clinical tests, types of treatment, prognosis and progress. A Progess Note is part of the client’s official records. The Gillman HIPAA note format is a style that can be used for Progress Notes and it complies with HIPAA requirements.

It’s important to note (pun intended) that psychotherapy notes and progress notes not be mixed together. Psychotherapy notes are specifically excluded from disclosure by HIPAA; if you create some kind of blended note, you’d be creating a record that could run afoul of disclosure requirements.

According to HIPAA rules, the following items are excluded from note confidentiality:

  • Results of clinical exams
  • Therapy session start and end times
  • Modalities of treatment
  • Medication

The Gillman HIPAA note format

The Gillman format provides a useful template that prevents you from inadvertently including protected information (i.e. psychotherapy note content) on the progress note.

Here’s how it works

  • Record the start and end time of your therapy session
  • Record the treatment modalities used
  • Summarize the symptoms, diagnosis, treatment plan and the prognosis.

Here’s what a paper version of the Gilman HIPAA Progress Note looks like:

Gilman HIPAA Notes

Gilman HIPAA

Published by Brian Dear

Brian is the cofounder and CEO of iCouch, Inc. He has an extensive background in software engineering, inbound marketing and mental health practice management.

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7 Comments

  1. The “Gillman HIPAA Note Format” was empty. No content found for p. 1 or 2. You may want to take this down.

    1. Thanks Elise for catching that! It has been fixed! We appreciate you reading and hope you found this post helpful (now that it has the correct images!)

  2. Thank you. Interesting format. Glad I saw it. You may wish to update the billing codes. Thank you for your prompt response and for sharing.

  3. Just a note about this site — the documentation examples on this site are outdated and inaccurate.

    (1) They reference CPT codes not used since before 2013 when new codes and Federal expectations were released. They are gender binary.

    (2) They are inaccurate re: legal realities of a process/psychotherapy note, which are protected from subpoena under HIPPA law revisions.

    1. Thanks for your comment. The provided example is just that, an example of the format. The Gillman note is not a psychotherapy note. It’s a progress note, which are defined differently under the law. Jaffee v. Redmond in 1996 established that psychotherapy notes are not discoverable, even with a court order, however, a progress note most certainly is, and that the Gillman note is.

      Regarding outdated CPT codes — that isn’t particularly relevant as this article is about the format of the note rather than the specific content. CPT codes change almost each year and of course, that requires a practitioner to update their documentation appropriately.

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