Therapy notes, progress notes, clinical notes—you may have heard these terms thrown around interchangeably. What’s the difference between them, and is your practice compliant with the privacy regulations for each type?
Failing to follow best practices for therapy notes and progress notes can have legal and professional repercussions.
What are Therapy Notes?
Therapy notes are a clinician’s private record of their patient encounters. Also called psychotherapy notes, these records help the provider keep track of what happened at each appointment. A clinician might record their thoughts, impressions, and feelings about the conversation, along with important details and topics they want to pursue next time.
These notes naturally contain sensitive information, and are kept confidential. They don’t appear in medical records and cannot be shared with a third party except by the patient’s written consent. Practitioners aren’t even required to share them with patients themselves. In fact, providers whose patients request these notes may want to think long and hard about granting the request. Notes that contain a therapist’s private impressions and interpretations of patient conversations may contain information that would not benefit the patient.
HIPAA regulates that therapy notes be stored separately from progress notes. They can be written longhand or stored digitally as long as the therapist is the only one with access to them. Something as simple as a locked filing cabinet or password-protected computer will do the trick.
Clinicians may keep therapy notes about everyone they treat, whether individuals, families, or groups.
Are you ever required to share therapy notes?
A variety of situations may legally require you to share therapy notes. The following is not an exhaustive list and state laws may apply, so check regulations in your state.
You might have to share your therapy notes if:
- They contain information that falls under your “duty to warn,” i.e. involves the threat of harm to self or others
- You receive a court order for documents and/or testimony (state laws may vary)
- The notes contain information regarding abuse or other topics covered under mandatory reporting laws
- A coroner or medical examiner requests them as part of an investigation
- The U.S. Department of Health and Human Services (HHS) requests them as part of an investigation
The Difference Between Therapy Notes and Progress Notes
Therapy notes are private records meant to help therapists remember patient encounters. Progress notes, on the other hand, record information relevant to the patient’s treatment and response to treatment. This covers information such as diagnosis, symptoms, medical history, test results, treatment plan, progress at appointments, prescription medications, etc.
Progress notes help other practitioners or treating physicians stay up-to-speed on your work with a patient, and they inform insurance companies of the reliability and efficacy of your methods. They can also protect you if questions arise about quality of care. Others who may access progress notes include the patient and their family members.
As with therapy notes, certain legal scenarios may compel you to share progress notes with a wider audience, such as before a court of law or during an HHS investigation.
Are “Clinical Notes” the Same as Progress Notes?
Not quite. While many use these two terms interchangeably, there is a technical difference. The broader term “clinical notes” includes all of a patient’s records (aside from therapy notes), including intake information, big-picture treatment planning, and the progress notes from each clinical encounter. In other words, progress notes are a subset of clinical notes; they report results of individual appointments, while “clinical notes” include comprehensive patient records.
Main Difference Between Therapy Notes and Progress Notes
One of the biggest differences between therapy notes and progress notes is the standard placed on progress notes. They must contain certain information in orderly formatting so other providers and insurance companies can easily use them. Therapy notes, on the other hand, need not make sense to anyone but the clinician.
Progress notes should record the date and time of service, provider name, CPT codes, diagnoses, medication records, and more. The complete list of items required on your progress notes may depend on your practice, the insurance providers you work with, and state regulations. This makes them more complicated than psychotherapy notes, particularly if your practice employs multiple providers who must all adhere to the same format.
The right software can streamline the process and make progress notes easier. Ideally, an EHR should allow practitioners to build progress report templates that makes sense for their practice. A strong clinical reporting feature should also make it easy to fill out the progress report during patient encounters so providers can focus more fully on patients.
Valant Can Help
If you need a secure EHR that is HIPAA compliant to support all of your practice’s note-taking needs, check out Valant’s clinical documentation features. Contact us today for a free demo, or to learn more about how our software can make your day-to-day workflow simpler.