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Demystifying Progress Notes and Psychotherapy Notes


What is the Difference Between Progress Notes and Psychotherapy Notes?

Written by Leslie S. Tsukroff, MSW, LCSW

Founder and Executive Director of Leslie S. Tsukroff, Inc.





Clinicians often express confusion between psychotherapy notes and progress

notes and during the workshop several questions were raised, so I’ll provide

clarity here.


What is a psychotherapy note?

HIPAA defines psychotherapy notes as:

“…notes recorded (in any medium) by a health care provider who is a

mental health professional documenting or analyzing the contents of

conversation during a private counseling session or a group, joint, or family

counseling session and that are separated from the rest of the individual's

medical record.”


Psychotherapy notes do not include any information that is maintained in a

patient’s medical record including, any information about medication prescription

and monitoring, counseling session start and stop times, the modalities and

frequencies of treatment furnished, results of clinical tests, or summaries of

diagnosis, functional status, treatment plan, symptoms, prognosis, and progress

to date. 45 CFR § 164.501


Where can I store psychotherapy notes?

Psychotherapy notes, if you choose to keep them, must be maintained separately

from the client’s medical record. If you are old school (like me) and maintain

physical (paper) records, your psychotherapy notes should be kept in a separate

notebook, Pendaflex or manila file and should not be comingled with the client’s

medical record.


Since psychotherapy notes may contain sensitive data, they should be kept under

lock and key, just like the medical record. If you use a practice management

system (PMS) to maintain an electronic medical record then you may keep paper

psychotherapy notes or if your PMS has the capacity to separate the medical

record from psychotherapy notes, you may enter them into your PMS.

For example, both Simple Practice© and TherapyNotes© have the capacity to

keep psychotherapy notes separate from progress notes in their systems, thus

adhering to the HIPAA mandate. In TherapyNotes©, clinicians who wish to

maintain psychotherapy notes do so by entering them into the Process Note

template while Simple Practice has a separate template called “Psychotherapy

Note”.


Can psychotherapy notes be subpoenaed in a legal proceeding?

Yes. Although under HIPAA psychotherapy notes receive special privacy

protections and are afforded a higher level of privacy than progress notes,

psychotherapy notes are not 100% protected. In general, HIPAA does not allow

the release of psychotherapy notes, even for treatment purposes, without the

client's prior specific authorization; however, under certain circumstances

exceptions exist. For example, in some situations, a court may order the release

of psychotherapy notes and this is consistent with several mandates set forth by

HIPAA. According to The Department of Health and Human Services, Office for

Civil Rights,

“A notable exception exists for disclosures required by other law,

such as for mandatory reporting of abuse, and mandatory ‘duty to

protect’ situations regarding threats of serious and imminent harm

made by the patient (State laws vary as to whether such a warning is

mandatory or permissible).”


Do I have to worry about any other laws?

Maybe. As with all issues regarding progress notes, psychotherapy notes, medical

records, access to/release of records, confidentiality and privacy etc., it’s

important to not only consider HIPAA, but practitioners should always check their

regulatory and state laws as well. States may define psychotherapy notes

differently than HIPAA does. In fact, some states:

1) Do not differentiate between a progress note and a psychotherapy note;

2) Permit clients and others access any and all information documented about them;

3) Give psychotherapy notes protective status.


Do I have to allow insurance companies access psychotherapy notes?

Probably not. In general, the information contained in psychotherapy notes are

typically not viewed as being helpful or legally required for treatment, payment, or

health care operations purposes, other than by the treating provider and

therefore, insurance companies should not be requesting access to such

information. If you are faced with a request for psychotherapy notes, before you act, I urge

you to contact your professional liability provider, your professional membership

organization, an attorney or Leslie S. Tsukroff, Inc. for further guidance.


Do parents have the right to access psychotherapy notes regarding their

minor child?

HIPAA does not give parents the absolute right to access psychotherapy notes.

HIPAA’s Privacy Rule differentiates information contained in the medical record

and a clinician’s psychotherapy notes and does not permit a minor’s personal

representatives the right to access to psychotherapy notes.


However, at the discretion of the clinician, HIPAA allows for the disclosure of information contained in the medical record and in psychotherapy notes to patients and their personal representatives. When parents request psychotherapy notes regarding their minor children, clinicians must consult their State laws to determine if other laws prohibit, limit or restrict such disclosures.


Are we required to keep psychotherapy notes?

No. Unlike progress notes which, in most states you are legally required to

maintain, psychotherapy notes are optional.


Is client art work considered psychotherapy notes?

No, work completed in session, including worksheets, assessments, artwork and

photos of sand tray creations should be maintained in the medical record, as they

are a part of the clinical work.


Final thoughts

If you only keep one set of notes, then those notes are automatically considered

progress notes, NO MATTER WHAT IS CONTAINED IN THEM. Therefore, it is

really important to make sure that the official notes you place in the client’s

medical record, meet the HIPAA criteria for progress notes and not psychotherapy

notes.


For a more in-depth look at Progress Notes, Psychotherapy Notes and Client's Rights of Access, consider signing up for the following workshops:

  • Minors’ Rights Vs. Parents’ Rights: Untangling the Web for New Jersey Clinicians

  • Everything You Need to Know—Documentation for New Jersey Social Workers in Private Practice

  • Audit-Proof Progress Notes: An In-Depth Look at Documentation and Record- Keeping in Private Practice

This document is for general informational purposes only and is not intended to be used as

advice (legal, ethical or technical) or as a substitute for the guidance of an attorney or an

individualized consultation. It does not address all possible clinical, legal and ethical issues that may arise, nor does it take into consideration the particular circumstances, nuances or concerns of the situation or person(s) involved. Leslie S. Tsukroff, Inc. does not assume any

responsibility or liability for any errors or omissions in its content.

© Leslie S. Tsukroff, Inc. 2023 (All Rights Reserved)

This article originally appeared in Leslie’s May 2022 Newsletter



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