Pros and Cons of Therapy Notes
Why You Might Take Therapy Notes During a Therapy Session
There are many reasons therapists take therapy notes during a session, and these notes do play an important role in your relationship with clients, but some therapists are opposed to them. Benefits include being able to stay on track with your client and having valuable insights written down to reference in future sessions. On the other hand, may therapists think they take too long and can distract a client during a session.
Today, we’re covering what therapy notes are, how they’re different than progress notes, and the pros/cons of therapy notes, so you can determine if they make sense for your private practice.
What Are Therapy Notes?
Therapy notes document the time you have with a client and contain information about the session you had with them. Think of these as your own notes (kind of like the notes you’d take in school or your journal), so your therapy notes might include:
Thoughts about your client.
Impressions about your client.
Feelings about your client.
Ideas about your client.
Realizations about your client.
How Therapy Notes Are Different Than Progress Notes
Therapy notes aren’t progress notes, which are created to document your client’s symptoms, diagnosis, and treatment plan. Because of this, therapy notes are protected under HIPAA, so clients and insurance companies cannot access them unless you’re legally required to under the law. For example, if a medical examiner requests them as part of an investigation.
Key Differences Between Therapy Notes and Progress Notes
Therapy notes are a therapist’s private notes or records of their time with their clients. They help you stay on track and provide you with a timeline of what happened during each appointment. These notes include thoughts, impressions, feelings, details, and ideas or topics you might want to explore with your client in your next session.
Progress notes are the who, what, and when of treatment. They include medical history, diagnoses, the client’s condition, current or previous treatment plan information, prescriptions, etc. They’re put in place to legally protect your client (and you as well) to ensure they receive the proper amount of care.
Should You Take Therapy Notes as a Therapist?
Whether or not you want to take therapy notes as a therapist depends on your preferences and how you like to interact with your client during a session. Benefits of taking therapy notes include that they help you stay on track, help you remember something significant you wanted to bring up from a previous session, and can support you in picking up on patterns and specific details that show up during your sessions. In this case, therapy notes can help you formulate your progress notes as well.
Pros of Taking Therapy Notes During a Client Session
Allows you to keep track of issues your client is facing.
Helps you create a timeline to see how your client is progressing.
Provides you with insight into how sessions are going.
Helps you stay on track if there’s a specific topic you feel needs to be brought up/addressed.
Keeps you aware of patterns and changes in your client’s behavior and overall well-being.
There are reasons not to take therapy notes during a session too. Taking a bunch of notes during a session could throw your client off or make them nervous. Note taking might also make your client feel like you’re paying more attention to your notes. For this reason, many therapists feel you should keep your note taking to a minimum.
Cons of Taking Therapy Notes During a Client Session
Distracts your client from the focus of the therapy session.
Sometimes makes the client feel like they don’t have your full attention.
Impacts the client-therapist relationship if your client doesn’t feel heard or validated.
The best thing you can do is to ask your clients if notetaking feels okay for them and listen and observe. Some may be totally okay with this process and others might feel uncomfortable or hesitant about it. Be sure to observe any reactions clients have toward notetaking during a session and check in after each session where you took notes to see how it made your client feel.
Can Clients Access Therapy Notes?
Therapy notes are private and protected under federal law, so there’s no need to share them with your client unless you’d like to do so. Be sure to check with your state regulations to determine if this is true for you.
Which Form of Therapy Notes Are Allowed: Digital, Paper, or Recordings?
Typing up notes on a computer may distract your client, so be sure to ask before doing so. Writing down a few notes on paper seems to be pretty common and there’s also the option of recording a client session too – with consent from the client, of course.
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Want more insight on progress notes and other processes in private practice? Be sure to check out our free private practice trainings for therapists. Some are even CE-eligible!
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