What's the Difference Between Therapy Progress Notes and Process Notes?

Connecting with your clients is important, but thats not the only part of your job as a therapist. Paperwork is just as important to keep your practice compliant. It's also necessary. 

When I started out as a psychotherapist, I was confused about all the different note types I had to write. We went over writing progress notes, some, during my studies. But, in the field, I felt completely unprepared. 

Have you been feeling confused too? What is difference between a progress note and process note for therapy? 

You don't need to feel embarrassed about now knowing the difference. Therapists get fuzzy with the distinctions between the different notes, all the time. There are a lot of different parts at play during a therapy session. 

If the administrative task of note taking for therapy isn’t your forte, we’re here to help, 

Let's begin with answering the main question. What's the difference between a progress note and a process note?

The Importance of Record-Keeping

Good record-keeping benefits both you and your clients. When you have clear documentation about your client's history, it makes you a better therapist. You can evaluate and treat the client better when you have a recorded history and plan. 

Timely and appropriate record-keeping also protects you and your practice. It's better to spend a few moments writing notes to avoid the potential risk of liability. 

It’s also important to know how privacy regulations affect the two, very different types of notes.

Psychotherapy Progress Notes vs Process Notes Defined

Psychotherapy Progress Notes

Progress notes are confidential records of a patient’s treatment and treatment response. 

They can include information on the following, and more:

• a patient’s medical history
• symptoms, diagnosis,
• test results
• treatment plan
• prescription medications
• progress throughout sessions

They can also serve a variety of purposes:

• Helping other healthcare professionals keep up to date on your client
• Informing insurance companies about the reliability and effectiveness of your treatment
• Protecting your practice if someone questions the quality of care

Psychotherapy Process Notes

On the other hand, psychotherapy notes (aka process notes, therapy notes, or private notes) are not meant to be shared. They’re a private record of your own thoughts and impressions during the session. 

In short, progress notes are shared, when requested. Process notes are your private thoughts and feelings about a client interaction. Process notes are not shared.

How HIPAA and Privacy Regulations Affect Your Therapy Process Notes

Under HIPAA, your therapy process notes are protected. This is due to the sensitive information contained and their personal nature. 

You’re obligated to prevent access to them by keeping them separate from your progress notes. If you don’t, others could gain unauthorized access which is a breach of client privacy. 

If the situation calls for it, you can release your process notes with your client’s written consent. They'll need to sign a special form. Examples of situations include a court order, grand jury subpoena, request from a government agency, or similar legal request. 

On the other hand, progress notes can be released without your client’s consent, or with generalized consent.

What is the Difference Between Therapy Progress and Process Notes?

To sum it up, what's the difference between a progress note and a process note? 

Progress notes record information about your client’s treatment. This includes session schedules, test results, diagnosis, treatment progress, and so on. Other healthcare providers can access these with generalized consent from your client. 

Process notes, also called psychotherapy notes, are more personal and confidential. They’re a record of your personal observations during sessions. These must be kept separate from progress notes. They can only be shared in specific circumstances. To share them you need express written consent from your client.

What Are “Clinical Notes”?

This is another term you may have heard thrown about. “Clinical notes” is a much broader category of patient records. These include progress notes from each session, treatment plans, and intake information. 

It includes everything except therapy process notes. You can treat progress notes as a subset of clinical notes. Progress notes for therapy report on individual sessions. Clinical notes offer a more comprehensive look at the patient’s overall situation.

Ready to create therapy progress notes with ease?

If writing progress notes from scratch feels like a chore, we've got a solution for you. You’ll definitely want to explore our point-and-click note generator, Clarity Notes. 

Our customizable tool allows you to pick from our comprehensive templates. We have lists of interventions that help you create progress notes with less hassle. 

As therapists, we set out to improve upon the existing note generator tools we’d been using for years. 

Unlike other tools, you can create and save your own custom phrases. You can easily access your most frequently used interventions and modalities by positioning them at the top of each section. It'll save this way and show up the same way each time you create a note. Why should you have to scroll or tab through interventions and modalities that don’t apply to your work? Save yourself precious time with Clarity Notes. Spend your free time doing something more fulfilling.

Are you ready to simplify the way you create progress notes? 

Try the Clarity Cooperative's Pro subscription with a free 30 day trial today!

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