Process Notes (Psychotherapy notes / Private notes) vs Progress Notes - Key Difference

Mental health clinicians have to document all counseling sessions that they complete. Unfortunately, writing notes can be difficult for many clinicians and becomes a dreaded task. As a result, you may have questions about what formats to use or what should go into a note. In addition to different types of note formats, different types of documentation have very different purposes.

You may have to distinguish between two types of notes if you’re a mental health clinician. Progress and process notes are commonly used types of notes in the mental health field. Process notes and progress are different types of notes that can be useful to the clinician, but only progress notes go into the client’s official record. Therefore, it may be helpful for clinicians to be knowledgeable of the differences between the two, especially for billing and audit purposes.

What is a process note?

A process note is a form of notation that helps clinicians document their psychotherapy sessions. Process notes are also known as “psychotherapy notes” or “private notes.” When you write a process note, they help you, as the clinician, keep track of your personal questions and hypotheses about the client’s treatment.

In a process note, you may include information such as:

• Questions to bring up in supervision
• An analysis of your thoughts and feelings
• Information for consultation with other clinicians
• Areas for further exploration in future sessions with your client

Psychotherapy notes are for the clinician’s benefit, as they are private notes about the client’s course of treatment. For example, if you see a client that presents information in a session that you may need to obtain consultation on, you may jot that down in a process note.

The definition of psychotherapy notes according to HIPAA is:

“Psychotherapy notes means 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 excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.”

Process notes are not required to be kept; therefore, they don’t have a format they follow. Recording psychotherapy notes in an EHR or jotting notes on a secured notepad are sufficient for process notes. It’s crucial that these notes remain kept outside of the client’s file and don’t include any client assessments, diagnoses, or treatment plans.

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What is a progress note?

Progress notes are much different than process notes. Progress notes are official parts of the client’s treatment record. Progress notes help document each psychotherapy session and assist mental health professionals and insurance companies in keeping track of the client’s progress in therapy.

Progress notes are essential to documenting your psychotherapy sessions with your client. Therefore, these are required to be kept by all mental health clinicians.

Documentation of progress notes can be kept in many formats, such as:

• DAP notes
• SOAP notes
• BIRP notes
• GIRP notes
• PIRP notes

These are different ways of documenting a psychotherapy session with a progress note. If you’re a mental health professional, you must keep progress notes to document what occurred during your session.

There is no one gold standard for keeping progress notes. In addition, each state or mental health profession may have different laws or ethics about what should be included in a progress note.

Some examples of what may be required in progress notes include:

• Demographics
• Date, time, and location of the sessions
• Client’s symptoms
• Diagnosis
• Appearance
• Mood
• Safety risk
• Treatment modalities used by the therapist
• Interventions
• Recommendations
• Client homework
• Client referrals
• Results of tests or assessments given
• Medical history
• Functional status
• Your signature

Insurance companies may also dictate what should be included in a progress note. It’s crucial to look up your state and payor’s mandates for what must go in a progress note.

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What are the rules and laws regarding process and progress notes?

Process notes or psychotherapy notes are usually only intended for the clinician. Process notes are private messages a mental health professional may leave for themselves to help them consult with others, remember to ask a supervisor about something, or analyze their thoughts and feelings on a case.

Due to their private nature, psychotherapy notes aren’t included in a client’s official record, and clients don’t have access to them. Therefore, they should be kept separate from the rest of the client’s medical history. You can only share process notes with third parties with written consent from the client.

If you bill insurance, process notes cannot be audited by insurance companies. In most cases, psychotherapy notes are private. Legally, there may be some instances where you would have to turn over your psychotherapy notes.

Law enforcement investigations, subpoenas from a grand jury or a court order, or government administrative requests are all potential situations where you would have to turn over process notes. Other conditions where you may have to release process notes include:

• Defending yourself in court
• When requested by a medical examiner
• Preventing public safety threats
• To assist medical examiners or coroners

Mental health clinicians are not required to keep process notes. However, it is still essential that you keep these notes in a secured area, such as a locked file cabinet or a secured EHR system, to avoid potential violations of the Health Insurance Portability and Accountability Act (HIPAA). In addition, process notes have additional safeguards through HIPAA and must be kept confidential.

Progress notes, on the other hand, are an official part of the client’s record. These types of notes comprise the client’s medical history. Clients can request copies of their progress notes, and insurance companies can audit them.

HIPAA laws also protect progress notes, and they should be kept confidential. Progress notes help clinicians and other healthcare providers track client progress, create treatment plans, and are vital to providing a high standard of care to clients.

To keep all note types confidential, consider storing them in an electronic health record on a locked computer or in a locked file cabinet in a room that can be secured.

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Process note examples

If you keep private notes about your clients, it may be challenging to know what should and shouldn’t go in a client’s official record.

While there isn’t a standardized format for process notes, here are some examples of what this may look like:

“I feel that my client isn’t being truthful with what they have reported in their therapy sessions. I will speak with my supervisor about this in supervision next week.”

“I need to look up some potential resources for my client in this area to provide them with the best care possible.”

“I feel like this client resists being here, and it’s an uncomfortable experience for me. However, I will obtain consultation on this case, so I don’t let this impact my rapport with this client.”

While these are examples of what could go into a process note, any information relevant to you as a therapist that falls into the definition provided in the HIPAA law can be helpful to document in a process note.

Process vs. Progress notes quick guide

Let’s review the similarities and differences if you want a fast reference on the differences between process and progress notes.

Process notes and progress notes similarities

A few similarities between both these types of notes include the following:

• Both should be kept confidential
• The clinician should secure both types of notes
• Can provide relevant information to the clinician

There are more differences between process and progress notes than similarities because they have different purposes.

Process notes

They also are known as private notes or psychotherapy notes. They are different than progress notes in that:

• They aren’t a part of the client’s official medical record
• HIPAA protects them
• They should exclude any diagnostic or treatment plan information
• They are for the clinician’s benefit only
• They are only subject to audits in rare circumstances
• Clients cannot access these notes
• Written permission from the client must occur for these to be released to anyone
• It can help analyze the clinician’s feelings and hypothesis
• Notes may be helpful for consultation or supervision
• Must be separated from the client’s record
• Process notes aren’t required to be kept
• Don’t have a standardized format

Progress notes

• Are an official part of the client’s record
• Document what occurred in a therapy session
• Can be audited by insurance companies
• Must be kept confidential
• Helps track client progress
• There are many different formats you can use to document progress notes
• Include relevant information about the client’s history
• Include the date and time of the session
• May include treatment plan information
• Include testing and assessment results
• Can be viewed by third-party payors
• Progress notes are required to be kept
• Have various standardized formats

If you have questions about what you should document after a session, checking your professional code of ethics and applicable laws in your state may be helpful.

References

https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/administrative/combined/hipaa-simplification-201303.pdf

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About the author

Marissa Moore

Marissa Moore is a mental health professional who owns Mending Hearts Counseling in Southwest Missouri. She specializes in providing affirming counseling services to the LGBTQIA+ community. Marissa has 11 years of experience working in the mental health field, and her work experience includes substance use treatment centers, group homes, an emergency room, and now private practice work.

Learn More About Marissa