In mental health care, proper documentation is essential for tracking a client’s progress, ensuring continuity of care, and maintaining legal compliance. Two common types of clinical documentation used by therapists and mental health professionals are psychotherapy notes and progress notes. While both serve important functions, they differ in purpose, confidentiality, and legal protections.
If you are wondering about the differences between psychotherapy notes vs. progress notes, this guide will provide a comprehensive comparison, including definitions, uses, and best practices for maintaining ethical and effective documentation.
What Are Psychotherapy Notes?
Psychotherapy notes are personal notes taken by a therapist during or after a session. These notes contain deep reflections, hypotheses, and observations that help the therapist process the session and plan future interventions.
Key Features of Psychotherapy Notes
- Purpose: Used for the therapist’s own reference to track personal impressions and insights.
- Content: May include personal observations, interpretations, hypotheses, and details about the therapist’s thought process.
- Confidentiality: Highly protected under the Health Insurance Portability and Accountability Act (HIPAA) and are not part of the official medical record.
- Legal Access: Generally not shared with insurance companies, clients, or other providers unless the therapist chooses to disclose them or is required by a legal order.
What Psychotherapy Notes Include
- Therapist’s reflections and personal insights
- Details about the client’s emotional responses
- Speculative thoughts about treatment direction
- Sensitive information not intended for medical records
What Psychotherapy Notes Do NOT Include
- Diagnosis or treatment plans
- Medication details
- Session summaries
- Client demographics
Because psychotherapy notes are meant solely for the therapist’s use, they do not contain clinical details required for billing, treatment continuity, or client access.
What Are Progress Notes?
Progress notes, on the other hand, are formal clinical documents that summarize a client’s treatment progress. These notes are part of the official medical record and are often required for insurance reimbursement, legal compliance, and communication between healthcare providers.
Key Features of Progress Notes
- Purpose: Document session content, clinical observations, and treatment plans.
- Content: Includes the client’s symptoms, therapeutic interventions, session progress, and goals.
- Confidentiality: Stored in the client’s official medical record and may be shared with insurance companies or other providers if necessary.
- Legal Access: Clients have the right to access their progress notes under HIPAA unless restricted for safety reasons.
What Progress Notes Include
- Date, time, and duration of the session
- Client’s presenting concerns and symptoms
- Therapeutic techniques used
- Progress toward treatment goals
- Any changes in the client’s condition
- Treatment plan adjustments
Because progress notes serve as a clinical record, they must be objective, concise, and factual while still providing enough detail to support treatment decisions.
Key Differences: Psychotherapy Notes vs. Progress Notes
| Feature | Psychotherapy Notes | Progress Notes |
| Purpose | Personal reflections for therapist’s use | Clinical documentation for treatment tracking |
| Content | Observations, hypotheses, sensitive details | Objective session summaries, interventions, progress |
| Confidentiality | Highly protected, not shared with insurers or clients | Part of the medical record, accessible to clients and providers |
| Legal Protection | Not required for documentation compliance | Required for insurance claims and audits |
| Client Access | Clients generally do not have access | Clients have the right to request access |
Best Practices for Writing Psychotherapy and Progress Notes
For Psychotherapy Notes:
- Keep them separate from the client’s official medical record.
- Use them strictly for personal insights and professional development.
- Avoid including factual details necessary for clinical documentation.
- Store them securely to maintain confidentiality.
For Progress Notes:
- Use an objective and structured format (e.g., SOAP or DAP).
- Document only relevant clinical details for treatment and billing.
- Ensure notes are clear, concise, and professional.
- Follow HIPAA guidelines to protect client privacy.
Final Thoughts: Which One Should You Use?
Both psychotherapy notes and progress notes play essential roles in mental health documentation. Psychotherapy notes are meant for the therapist’s personal use and are not part of the medical record, while progress notes serve as official documentation that tracks a client’s clinical progress and can be shared with necessary parties.
For ethical and legal compliance, therapists must keep these notes separate and ensure that progress notes remain objective and professional while psychotherapy notes are used for personal insights and treatment planning.