How to Write Psychotherapy Progress Notes

Patricia C., Ph.D.
Clinical Psychologist
notedesigner.com

Introduction:

When I was starting out as a psychologist in private practice I agonized over the issue of keeping psychotherapy progress notes. Though we were given some general direction during my training, I remained overwhelmed whenever I was staring down at the blank page after a session with a client. Typically I would end up writing far too much as I tried to capture the complexity of what had gone on between my client and myself and the many themes and processes at play. Frustrated, I would then sometimes neglect my notes for a time and end up feeling anxious and guilty regarding my work and professionalism. As my practice grew and I began seeing many more clients, the situation only became more unmanageable.

In speaking with a number of colleagues, I was pleased to find that I was not the only one experiencing this (indeed, one of my colleagues disclosed having given up on record keeping altogether!). To add to the anxiety was the fear of being inspected by my professional order and to be found lacking. After some time struggling with this issue, I began exploring various recommendations about how to write appropriate session notes. Just to clarify, by 'psychotherapy session notes' or 'psychotherapy progress notes' I do not mean the detailed 'process notes' that one writes to explore a session in depth – such as what one brings to a supervisor or for one's study of the psychotherapy process. That type of note is far too revealing, detailed, and often includes our more personal reflections and conjecture regarding a case – this is not the type of information to be kept in the client’s official file. An important reason that these process notes are excluded from the official record is that they may reveal information that may be hurtful or even damaging to the well-being of the client if read by the client himself or herself or by a third-party who may gain access to the clinical record. Indeed, most regulatory bodies (such as HIPAA in the US) do advise that this type of information be explicitly left out of your official clinical files. So then, what do we put in a client’s official file and how can we discipline ourselves to write and maintain appropriate psychotherapy session notes?

In the pages that follow, I am going to explain and demonstrate (using examples and templates) what I have discovered to be a helpful, efficient and structured way to write psychotherapy notes. This should be useful to mental health professionals in private practice, clinics, and other service centers. Students, interns and junior colleagues in particular will benefit from getting an early start on good psychotherapy record keeping and in establishing and maintaining their files without undue stress and anxiety. As someone who is a dedicated teacher and supervisor of therapists in training, I am also happy to share my recommendations with training centers, institutes, and clinical supervisors. In fact, if you have any suggestions or would like to make some additions to my recommendations, please feel free to email me at notedesigner@bellnet.ca.

Note: Recommendations and examples presented are intended to provide a general overview of how to write psychotherapy progress notes and do not constitute nor can they substitute for legal counsel or official guidelines mandated by any particular professional order or other regulatory body; please be sure to consult and familiarize yourself with the guidelines and rules regarding record keeping in your particular mental health field and/or as stipulated by your profession.

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