Therapy Notes: Your FAQ's Answered

>> Dealing with notes from months ago.

>> Worrying about notes sharing too much information if revealed in a legal proceeding.

>> Spending too much time writing notes because of worries about insurance audits.

These are the concerns many counselors share with me about their progress notes. 

I've been collecting a database of questions I commonly receive about progress notes and figured it's about time I focused on answering some of these!

There’s a lot of information in this post, so here is an outline of everything below:

1. Writing Progress Notes Late (weeks or months after a session)

   1. How late can I write progress notes if I’m behind?

   2. What can I do if too much time has passed since the session and I don't remember anything to write as a progress note?

2. How Much To Include In Progress Notes

   1. I feel I write too much... that is how I remember things actually. Should I then do a summary for the legal notes?

   2. How much specific detail do you include regarding session details and/or thought process in how you arrived at a decision?

3. Worries About Insurance Audits of Therapy Notes

   1. I'm finding myself writing 1-2 page progress notes. Since I've started taking insurance, I've become stressed with note taking.

   2. How to document in a problem focused way to satisfy insurance, disability, etc when the session is strength based and optimistic.

4. HIPAA & Progress Notes

   1. What are psychotherapy notes based on HIPAA?

   2. It appears that process notes can also be subpoenaed. How do we keep non-clinical case notes for our memory sake?

Remember that my goal is never to tell you exactly how to do something. I am a strong believer in multiple correct answers or ways of doing things (in most circumstances). But I do hope to offer you some food for thought in my answers below.

These are all real questions or concerns brought up by other therapists... and I hear them over and over again: 

1.Writing Progress Notes Late (weeks or months after a session)

"How late can I write progress notes if I'm behind?"

You can (and I would say, should) write any note that isn't written. That means if the note is from last year, write it! If it's from last month, write it! There is no expiration date on writing notes.

Now, if you're like me, there may be an "expiration date" for your memory. And there are certainly expiration dates for things like insurance claims, so that's another story. But having a complete story in your client's record is always important. 

I do recommend that if it's been a long time (this is subjective but let's say more than a month), include something like "Late Entry" at the top of your note. 

You're not trying to hide anything and since you should sign and date all notes on the date of entry, that won't match your session date. This is simply providing an explanation for why those dates are off.

"What can I do if too much time has passed since the session and I don't remember anything to write as a progress note?"

Sometimes this happens. And it sucks. 

Do what you can but NEVER make up information that you don't remember. 

If you honestly can't remember what happened but you're certain your client did show up for the session, here is a brief example progress note...

Late Entry. Client attended session. Addressed treatment goals. Next session planned for xx/yy/zz.

Is that a good note? Of course not. But let me tell you, it's still better than no note at all and you're not compromising your integrity. Admit that the situation sucks, create a plan so it doesn't happen again, and move on. 

2. How Much To Include In Progress Notes

"I feel I write too much... that is how I remember things actually. Should I then do a summary for the legal notes?"

My short answer is no, I do NOT recommend writing two sets of notes! That’s the opposite of simplifying things. However, I get it because I have a horrible memory due to my ADHD and so I have some other recommendations to improve your case and make them easier to write.

I recommend asking yourself some key questions while writing:

• What was the theme of our session?

• What stood out to me as important about our session? 

• What seemed important to my client during our session?

• What do I want to follow up on? 

• What do I think will be really important to have written down for later?

Try to keep your answer to each of those questions to one sentence, then use that as the basis for what you include in your notes. This process may take a little more time initially, but you'll be able to train yourself to think about these things when you sit down to write notes.

Another recommendation is to use my favorite progress notes template so you have a combination of checkboxes AND written data that personalizes the session. This way you can remember what happened, have a complete case note, AND reduce the amount of time you’re spending writing progress notes.

The process will get easier and faster over time. And you know what? You may simply write a little more in your notes than another therapist. And that's okay.

>> It's okay to have good, objective information in your notes. We worry a little too much about having "too much information" in our progress notes. But if you want some more guidance on how to pare things down, check out this blog post where I give an example of how to do that.

"How much specific detail do you include regarding session details and/or thought process in how you arrived at a decision?"

Here's a vague answer you'll hate- however much it takes to explain your rationale.

Seriously though, if you're in a situation where you're documenting why you made a clinical decision, you're likely dealing with something that could potentially be high risk or an ethical dilemma or the like. This is NOT the time to skimp on information!

Provide the applicable laws or ethical principles, information from research or consultations you did, and how all of those things contributed to your decision. This is the basis for your rationale. 

Sometimes this can be accomplished in 1-2 sentences, sometimes it will take 1-2 paragraphs. It simply depends on the situation. 

3. Worries About Insurance Audits of Counseling Notes

"I'm finding myself writing 1-2 page progress notes. Since I've started taking insurance, I've become stressed with note taking."

Notes for clients who use their insurance aren't drastically different from notes for clients who pay privately. The biggest difference with insurance is that you want to consider medical necessity. 

I have a much more detailed blog post on insurance requirements for writing therapy notes, but I can summarize by saying that you do want to make sure you're following a treatment plan that is focused on the client's diagnosis and you want to address two things in every case note:

1. Progress made

2. Ongoing need

This is the fine line with insurance. If therapy isn't helping your client in the long-term, they may choose to no longer pay or not to approve further sessions. However, if you only focus on progress and your client is getting better then it can appear your client no longer needs services.

>> Insurance is usually not concerned about your specific interventions or treatment modality (although it does apply in some cases). They simply want to see that they are paying for a service that is meeting the member's needs. 

And yes, they usually do want to see how they can do that more cheaply. Let's be real. So make sure you consider that, too.

Ask yourself these questions when writing counseling notes for clients who use their insurance:

• How is ongoing therapy keeping your client from deteriorating, or from needing more intensive treatment?

• How is therapy improving their health or relationships?

These are all things that make therapy a very cost-effective treatment when compared to things like hospitalization or tests for somatic presentations of symptoms. 

"How to document in a problem focused way to satisfy insurance, disability, etc. when the session is strength based and optimistic."

Continuing our discussion from the answer above, you want to include honest information about the progress (or lack thereof) that your client is making, as well as their ongoing need. 

Personally, I work from a strengths-based perspective, but that doesn't mean I'm ignorant to the reason my client is seeking therapy.

They have a concern and that manifests itself in ways that are impacting them negatively. To gloss over this or pretend it's not a concern is actually quite demeaning, disempowering and invalidating.

Documenting this and addressing it is a critical component of enacting change and working through any problem. Documenting this problem does not place blame on the client or invalidate any of their strengths. In fact, it does quite the opposite.

So yes, include the strengths and the wins. Absolutely. 

And then also include what continues to be a concern, a problem, a need. Identify what didn't work or continues to be a struggle.

>> Document the full journey your client is on and you'll have a beautiful narrative that highlights their resiliency and strength throughout. 

4. HIPAA & Psychotherapy Notes

"What are psychotherapy notes based on HIPAA?"

This is a BIG topic and for a more complete answer, I recommend checking out this post on what you MUST know about process notes. But here are the basics with psychotherapy notes per HIPAA...

1. Psychotherapy notes are what we commonly refer to as process notes.

2. Psychotherapy notes are optional and MUST be kept separate from the client record to receive their distinction.

3. Psychotherapy notes are NOT progress notes (case notes) that discuss ongoing treatment.

Why they decided to use such a confusing term, I'll never know! But per HIPAA, psychotherapy notes are those optional notes you might write to yourself about sessions or clients, to jog your memory, etc. As such, they receive special privacy and clients are typically not entitled to them. 

However, these never take the place of progress notes, which are the ethically and legally required notes all therapists do need to take. 

So yes, if you choose to write process/psychotherapy notes, you are choosing to write two different notes for sessions. For some therapists, this is a really important part of their own process. For others, it is simply an extra burden and they choose not to do it. 

In case you're wondering, no, I don't write process notes myself. But I also share notes with my clients on a regular basis, so I often do things a little differently ;) 

"It appears that process notes can also be subpoenaed. How do we keep non-clinical case notes for our memory sake?"

Yes, they can! It is a common misconception that process notes (psychotherapy notes as discussed in the previous question) receive such special treatment they cannot be subpoenaed. 

However, it is very rare that psychotherapy notes are ever subpoenaed and I would guess that if they are, whomever is requesting them is often intending to request progress notes instead. It is always best to call your client and discuss the reason for the subpoena, see if they are providing consent to release records, and to then assert privilege when applicable. 

Unfortunately, since the definition of psychotherapy notes is basically any notes you take about clinical treatment for your own purposes, I can't think of a way to ethically do that so they are never potentially subpoenaed. 

Remember though, that process notes can be whatever you want them to be. That means you can use abbreviations, shorthand, your own illegible handwriting... whatever you want! You do not have to worry about these notes being ready for scrutiny. 

>> That being said, the one thing I would encourage you to consider is how your client may react if they saw the notes. Although it is highly unlikely that will ever happen, you wouldn't want to have anything that could be offensive. I'm not saying to avoid writing things that are true, but do consider how you word things. 

Want to see some actual examples of progress notes?

Join the Private Practice Paperwork Crash Course and you’ll get immediate access to a FREE mini documentation training, complete with progress note examples and a treatment plan template.