What’s the difference between a process, progress or psychotherapy note? While those terms are often confused, it’s pretty simple. A process note is the same thing as a psychotherapy note. They’re synonyms. A progress note is something different. This article should clear it all up and provide you some guidance as to the HIPAA and disclosure implications of each.
Process and Psychotherapy Notes
A psychotherapy note is the note you write during a session. It’s your incoherent scribbles, your raw impressions, your stream of thought. These notes might include initial impressions, hypotheses, observations, thoughts or feelings. It’s essentially a tool for you to do the best job that you can. It’s a reference you might refer to when creating a treatment plan or documenting your client’s progress.
Psychotherapy note are private and a client does not have the right to ever see these notes. They are not a part of the medical record. Insurance companies can’t see them. That wasn’t always the case. Prior to the HIPAA privacy rule, insurance companies could make coverage decisions based on psychotherapy notes.
Since psychotherapy notes aren’t an official part of a client’s record, there is no prescribed format. You can write them however you want. Many of our users at iCouch, while they’ll use our electronic fillable forms for progress notes, treatment plans or other standardized forms, they’ll use paper and pen for their psychotherapy notes and upload a scan or photo of the notes to store in the system. The point is: write psychotherapy notes however you want!
Psychotherapy notes do not contain anything related to medical records or treatment. That would include medication details, diagnosis, progress summaries, or a treatment plan.
If you want or need to share psychotherapy notes, you must obtain authorization from the client except in a few narrow circumstances:
- To defend yourself in court
- As part of a Health and Human Services investigation
- When there is a serious danger to public safety
- To support a medical examiner or coroner
If you want to read more about subpoenas and how to handle them, the Zur Institute has a great article that is a must-read for all behavioral health practitioners.
Psychotherapy notes are subject to the same HIPAA protection requirements as any other protected health information but the difference from the rest of the medical record is that psychotherapy/process notes are subject to far less situations where disclosure is required.
A progress note communicates treatment plans, medical history or other similar information. It’s designed to be shared with relevant members of the healthcare team. It’s part of the official medical record for a client. Essentially when someone requests their “records,” progress notes are generally to what they are referring. Progress notes help insure the continuity of care when a client sees new or additional health care providers.
Progress notes generally follow a template. There are many different formats for progress note templates, the Gilman HIPAA note format is a popular example. SOAP and DAP are also fairly common, though SOAP tends to be more popular among the medical community, but therapists also use it as well.
Of course, progress notes are protected under the HIPAA Privacy Rule. Progress notes are required to be disclosed to a client as part of a medical records request. Progress notes can be disclosed without client consent in a larger variety of situations compared to psychotherapy notes. For example, progress notes can be disclosed with client permission in the following circumstances:
- In support of an essential government function
- To comply with worker’s compensation laws
- Threats to public safety
- To coroners and medical examiners
- For judicial or administrative proceedings
- For law enforcement
- For use in health oversight/auditing
- To government authorities in cases of domestic violence or abuse
- For public interest as required by law
- For research purposes
- Other purposes as required by state or federal law
Hopefully you have better clarity as to the differences between psychotherapy and progress notes. This article is meant to be informative, but of course, if you have any doubts or questions relevant to your jurisdiction, consult an attorney experienced with health care issues.