Consistent and accurate documentation represents a crucial component of any mental health treatment. All therapists are required to maintain progress notes on their clients' behalf. These notes track progress, and they enable clients using health insurance to continue receiving coverage for clinical services.
That said, therapists often find writing notes to be tedious and overwhelming. But this often speaks to the reality that many providers are untrained when it comes to the best standards in documentation. High caseloads and complex clinical cases can also make the note process more challenging.
Keeping appropriate, timely progress notes is an essential part of the work, and mastering this skill is imperative for both your clinical standing and your clients' overall treatment.
Understanding Therapy Progress Notes Vs. Process Notes
Therapy progress notes represent a standard form of clinical documentation. They become part of a client's official medical record, and they assist with keeping track of a client's progress. All mental health professionals are legally required to maintain such notes. Every progress note needs to adhere to a specific format that aligns with a client's specific treatment plan.
At a minimum, progress notes include:
- information about your client's history
- assessment of your client's progress
- details about your client's behavior in session
- any information related to client crises
Progress notes need to also include justification for treatment as well as how the client is responding to the treatment itself. All progress notes should be consistent and maintained within the client's record.
These notes also communicate treatment plan information between providers, and they may include past treatments, diagnoses, clinical tests, and medication prescription information.
Psychotherapy Notes/Private Notes
According to the health insurance portability and accountability act (HIPAA), process notes (or psychotherapy notes) are intended to document or analyze the contents of conversation occurring within a private counseling session.
Your own private notes can be essential for remembering important details that aren't necessarily relevant to a client's symptoms, prognosis, and progress. Many therapists jot down specific names or dates to better remember key parts of a client's story. Having this memory recall is often an essential part of building and maintaining rapport.
A therapist's personal notes include information related to:
- questions or reflections to discuss in supervision or consultation
- your own countertransference or reflections
- desired areas of further exploration with the client
Unlike progress notes, process notes are not mandated, and you don't have to follow any specific format when writing them. However, these notes must be kept separate from the client's file, and they should not include formal assessments or diagnoses.
If you bill insurance, your process notes can't be audited by healthcare providers. These notes remain private, although there may be some legal cases where you must share them (i.e. you've been ordered by a judge or you're intending to prevent public safety threats).
Best Universal Practices for Mental Health Progress Notes
Every mental health professional uses their own discretion and nuance when they write therapy progress notes. But it's still important that documentation adheres to a certain set of standards. This ensures compliance with your own laws and ethics, but it's also in the best interest of the client. If you're using a third-party payer for services, such as an insurance company, your notes may be audited at any time.
Failing to comply with certain requirements can result in payment clawbacks and losing the ability to panel with certain providers. From a legal standpoint, lacking adequate paperwork can result in therapists losing their licenses or being charged with negligence.
Although there are different expectations for documentation based on the particular organization or health insurance company, some universal standards generally apply.
Using an Electronic Medical Record or Electronic Health Record System for Progress Notes
Although some therapists might opt to use the old-fashioned paper-and-pen method for documentation, most people find that it's significantly easier to use an electronic system. This becomes a necessity if you accept insurance or intend to provide superbills for your clients.
These services provide HIPAA-compliant portals to store all treatment plans, progress notes, and anything else related to a client's medical history. You will also store all intake questionnaires and relevant assessments in these databases. Finally, secure portals allow you and your clients to communicate safely and in a way that still respects their protected health information.
Being Consistent and Timely With Keeping Progress Notes
All treatment plans and notes should be completed as soon as possible. Ideally, you should finish each progress note within 24-48 hours of meeting with the client.
If you fall behind on your documentation, make it a priority to catch up. The more time that lapses, the more likely you are to forget crucial information. Likewise, there's an increased liability if something happens to you or your client, and you don't have sufficient, up-to-date documentation about their treatment.
Updating Progress Related to the Treatment Plan
Psychotherapy notes should be relevant to how a client is progressing according to their treatment plan. If a treatment plan needs to be revised, that should be done accordingly, and it's important to document the reasons for making such changes.
Each progress note should also include which interventions were used and the broader context into where they fall. These interventions help substantiate the treatment goals and measure ongoing progress.
Maintaining Confidentiality Within Notes and Progress
Therapy inherently entails an exchange of sensitive information. With that, it's important to consider how your therapy progress notes support and maintain client confidentiality.
This can feel like a fine line, but it may be helpful to ask yourself, "How would my client feel if these notes were turned over via a court order?" If you feel concerned about how you describe any information, you need to reevaluate your documentation strategy.
- Avoid long-winded client quotes: Keep direct quotes to a minimum, and ensure that they are specific to treatment or safety planning. For example, "Client reported, 'I sometimes wish I wouldn't wake up in the morning,' which promoted suicide assessment and safety planning."
- Avoid using emotion-laden language: Consider using clinical terms like dysphoric/euthymic/flat/blunted when describing mood and affect instead of happy/sad/angry (unless you are using a direct quote).
- Maintain ownership over your own observations: Use statements like, "This writer noted," or "The client reported" to categorize who holds responsibility for a certain action or thought.
Using a Consistent Note-Taking Format
Whether you use SOAP notes, DAP notes, BIRP notes, or another format, consistency is key. Ensure that you use the same type of format for all your clinical notes.
If you conduct group therapy, you should also follow the same note format for each group session. This keeps treatment organized and cohesive.
Documentation Mistakes to Avoid Making
Clinical notes should be appropriate and to the point. Of course, there isn't a perfect process for writing or maintaining notes. But here are some common mental health professional documenting mistakes to avoid:
Using Subjective Criteria in the Wrong Sections
Every process note should discern subjective from objective data when it comes to a client's treatment.
Subjective data: This refers to the clinician's own opinions, interpretations, and clinical observations. For example, "He presented as more depressed than usual," or, "She appeared engaged and motivated to talk about her marriage," are both examples of subjective data.
Objective data: Objective data is measurable and quantifiable. This section needs to focus on any factual information supporting a client's diagnosis, physical or behavioral symptoms, appearance, orientation, and overall affect. An example of objective information includes, "Client presented as alert, oriented to time and place, and displayed a flat affect in session. He was groomed and neatly dressed. He replied to questions promptly and maintained good eye contact."
Failing to Provide Supporting Facts
Therapy notes should not include statements lacking supportive facts. It is not enough to say, "Client was eager to talk about her anxiety." You need to include relevant details that support this claim. For example, you might say, "Client was eager to talk about her anxiety as demonstrated by her discussing a recent conflict with her spouse that evoked feelings of panic and dread."
Using Too Many Abbreviations or Shorthand Terms
Always consider that someone who reviews an individual's medical record may not inherently know specific clinical terminology. When in doubt, write the full term out. Shorthand may be tempting when you're trying to save time, but unless it's obvious to all mental health professionals, keep original terms.
Failing to Include the Next Course of Action
It's important that your notes include your intended next steps for upcoming sessions. Aim to stay aligned with the client's progress and treatment plan without reinstating what's already been written. Make sure you include items that both you and the client have agreed to do and note any potential obstacles that may impede the client's progress.
A sufficient plan reads like, "Client and therapist will meet for their next therapy session on July 14 at 10:00 am. Client will be attending a family counseling session with an assigned family therapist on July 10 and will review the content of this session in therapy. Client reports he will exercise 3x this week and take his new depression medication as prescribed."
Using Moral Judgments
Be mindful of using certain terms that imply bias or moral judgment, including "good," "bad," "ugly," "attractive," or other related words. While psychotherapy notes can and should include a therapist's subjective opinions, it's not your job to deem which decisions or behaviors are superior to others.
With that, aim to also avoid using slang, poor grammar, and bad spelling. Avoid using any absolute language, including "always" or "never." Remember that cultural sensitivity is important for all mental health progress notes. Assume that a client, at some point, could have access to their psychotherapy note.
Making Notes Too Lengthy and Detailed
Progress notes should include enough information to paint a clear picture of a client’s progress and what occurred during the specific session. It should also outline plans for future sessions.
That said, it's generally advised to keep points concise and matter-of-fact. Aim to be clear and definitive, but don't provide so much detail that you're including unnecessary information. It's most important that you capture the main themes of the session as well as anything that relates to treatment goal progress.
Failing to Maintain Record-Keeping Standards
Appropriate record-keeping is a vital component of your clinical work. You're still responsible for holding onto notes after the therapy relationship ends.
Each state typically has specific guidelines indicating how long you must hold onto therapy notes. For example, the APA recommends that therapists maintain records for at least 7 years, although some providers advise keeping them for longer, as earlier information can prove to be valuable should you resume work with a client at a much later point.
For this reason alone, most therapists opt for electronic documentation, as it creates a simpler storage system for client files.
Final Thoughts on Strengthening Clinical Documentation
All mental health practitioners should strive to improve the quality of their progress notes throughout the duration of their careers. As care becomes more integrative, and clients increasingly use third-party payers to authorize treatment, the need for accurate documentation becomes more paramount.
