What Is The Purpose Of Therapists Notes?
Many people find themselves feeling intimated or confused about counseling. You might notice that your therapist uses a notepad or note-taking device during counseling. The use of notes by a therapist during a session may be regarded with questions, uncertainty or a degree of skepticism.
Some patients could feel comfortable with note-taking. Others might feel uncomfortable or worried that clinical notes are a form of judgment or disapproval from their counselor. Some people might feel uncomfortable knowing their counselor is using a discreet note to keep track of their progress in-session.
Learning about why therapists take notes can be beneficial in understanding the overall treatment process, and the possible range of benefit that a patient can gain from routine practice visits. Read on to learn more.
Why do counselors take notes during therapy sessions?
There are many potential reasons for therapists notes. There are also a variety of purposes that therapy notes can serve, and they may come in many forms.
Documenting symptoms
The symptom history might contain steps the client has taken to improve their situation, potential positive or negative factors and reported symptoms. As therapists develop a treatment plan, they might consider past notes and patient history before deciding on a plan forward.
Concerns and complaints
The concerns and complaints that patients discuss can be essential for therapists to document in psychotherapy notes; whether they are done manually or via a practice management software. How patients express their concerns can be insightful information to consider as a therapist assesses their personality or options for treatment plans. As a patient discusses a concern, the therapist may quickly note what they are experiencing. If it becomes relevant in the future, they might re-address it with their client.
Therapists might also develop concerns during a session. They may worry about their client's mental health, consider a diagnosis or wonder about a client's safety. They might also mark something to research after a session or follow up with their client. If therapists don't take notes, they may forget about these concerns in later sessions or confuse them with another client.
Session details, patterns, and changes
When working with a patient, therapists, social workers and other behavioral health professionals may have legal and ethical responsibilities. These responsibilities can include listening to the patient during sessions and taking note of patterns that occur during sessions. This sensitive information could be a subject matter that reappears in sessions, how patients articulate themselves or common emotional responses noted in therapy. If there are any unusual occurrences, such as missed sessions or sessions which start earlier than usual, most therapists might include information about it.
Additionally, if there are any ethical or legal concerns, a therapist may be required to report them. For example, in many countries and states, a therapist is a mandatory reporter that reports life-threatening risks to a client, themselves or others.
If you are experiencing suicidal thoughts or urges, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or text 988 to talk to someone over SMS. Support is available 24/7.
Mental health of the patient
Jotting down information regarding a patient's mental health can be part of the treatment plan. One therapist might ask you how you feel on a scale of 1-10 or if you've had any distressing symptoms since your last session. They might log these to track the progress in your sessions and how much therapy has benefited you.
A patient's mental health notes can help therapists determine how sessions are coming along, which strategies move the process forward, and what changes might be worth making in the treatment plan.
Improving your sessions
Many therapists may take notes for the sole purpose of supporting their patients and improving the quality of their treatment. They might also experience difficulty with memory or organization and use the notes to keep track of their patient's details to be as attentive as possible. If they have a long-term client, they may look back on old notes to see how a client has grown or changed throughout the years.
Not every counselor takes notes
Some therapists might opt out of notetaking or use alternative note-taking strategies. Some may take notes after a session or only file specific worksheets or documents about a client. Not all therapists provide treatment in the same way, so it may not necessarily mean your therapist isn't paying attention or isn't trying to support you.
If you attend therapy online, you may not notice whether your therapist is taking notes. Depending on their care strategy, note-taking can be a personal choice for a therapist.
Can I ask my counselor what they wrote?
Many patients who witness their therapists' notetaking may wonder about the reasons behind them and ask to view their files. It can be normal and okay to ask your therapist to see your notes. However, please note that they may not show you.
If you are partaking in sessions and feel curious or uncomfortable as your therapist is taking notes, you may ask them to let you know what they are writing about. If you feel nervous, you can tell them how you feel. They may understand and try to support you through the discomfort. It can also be important to note that these notes are not part of your medical record; they are generally for the therapists to use to provide a higher level of care.
Does my provider have to show me my file?
Depending on the laws in your state, therapists may be within their rights not to show you their notes. These laws might exist to uphold a good relationship between a counselor and their client. Some therapists might agree to let you see your notes when the session ends so they can clarify any information you don't understand.
Notes taken by a therapist might contain information that a client disagrees with or may be written quickly without professional terminology. In some instances, seeing and reading these notes could upset the patient and cause them to retreat from therapy that is helping them. If you want to read your therapist's notes, you might first consider how you might feel if you see another individual's opinions about your treatment. It can be helpful to rememeber that you may be working with your therapist for support—so if looking at the notes may cause you more nervousness, it may be better to avoid doing so.
Alternative counseling options
A growing body of research points to online therapy as a valuable treatment method, as many online therapy platforms may allow patients to view notes or responses from their therapist. One study published in the Journal of Mental Health showed the benefits of online connection to detailed therapy notes for those undergoing treatment. Researchers interviewed patients who'd been given connection to session notes online, with 94% reporting that the ability to review them was helpful and 87% reporting that they'd like to continue the practice. The study suggested that connection to therapy notes online can increase patient engagement in treatment and improve the relationship between mental health professionals and participants.
Online platforms can provide practical, engaging tools as you work to improve your mental health. You may also choose between telehealth sessions that include phone, video or live chat sessions with a licensed therapist. Through a platform like BetterHelp, you may have a record of all messages you've sent to your therapist. If your therapist is comfortable doing so, they may also provide session notes or resources with you.
Takeaway
Therapy notes may improve a client's treatment plan and can allow a therapist to retain essential details. This process could feel confusing, so asking your therapist about their reasons for taking notes might be beneficial. If you have not signed up for therapy before, you might consider reaching out to a counselor with an open-notes policy or that doesn't take notes to learn more and receive guidance in a way that feels comfortable to you.
What do therapists write in notes?
The content of therapist notes can depend on a variety of factors, including:
- Type of therapy provided
- Patient complaints and symptoms
- Local record-keeping regulations
- Individual therapist preferences
Many therapists will reserve note-taking for significant details about a patient’s personal or medical history, focusing more on active, attentive listening when possible. They might limit extensive note-taking to the first one or two sessions.
In other cases, a therapist might use notes to record changes in reported symptoms or the outcomes of specific therapeutic interventions (such as a patient’s response to a recommended deep breathing exercise). This is especially common in methods like cognitive-behavioral therapy, which often rely heavily on quantified self-reports of symptoms and manualized treatment plans. Psychodynamic therapists may also write down certain things patients say or do that could offer insights into their thinking, such as repeated turns of phrase.
Treatment providers may be more likely to take notes on things that might warn of danger to the patient or others. For instance, a therapist who hears a comment about suicide will often note it down so that they can follow up on it at an appropriate time and make sure the client is safe.
Can I ask to see my therapist’s notes?
You can always request to see your therapist's notes, but there’s no guarantee that they’ll agree. While you have a right to view your clinical records, including any “progress notes” your therapist keeps there, these are different from the “process notes” or “psychotherapy notes” taken during sessions.
Process notes are typically intended primarily to help therapists organize their thoughts and keep track of important information between sessions. They’re often kept separate from a patient’s clinical record, and they’re held to a higher level of restriction than progress notes. Psychotherapy notes are generally not given with other mental health professionals.
Despite this higher standard, your treatment provider may be willing to give the notes from your sessions if you ask. Some therapists have even begun experimenting with taking notes in an electronic system that patients can get at will, or even turning note-taking into a collaborative process in which the patient also participates.
How do you do TherapyNotes?
TherapyNotes is an electronic health records (EHR) system tailored to psychotherapy providers. It’s one of many digital tools that a therapist might use to log notes about a patient’s treatment. In addition to enabling digital process notes, TherapyNotes includes multiple features designed to facilitate things like documentation of care, insurance billing, medical record-keeping, and telehealth. The software includes several different therapy note templates to aid in organization.
Not all therapists will use electronic systems like TherapyNotes for note-taking. Many prefer to write down their observations by hand during sessions, and then transfer relevant details to a patient’s clinical record later on. Other therapists might employ a digital system for streamlined progress notes while keeping their process notes separate.
How do you write mental health notes?
Different mental health professionals may use a variety of note-taking approaches during psychotherapy. Some may record detailed observations throughout a session, some might jot down only brief reminders of the most clinically significant points discussed, and some might avoid all note-taking until after a patient has left their office. Your provider may use a therapy note template to help them organize their observations and capture relevant details, but they may also take notes in a more free-form manner.
When writing notes in a patient’s official mental health record, many therapists employ SOAP notes, a standardized form of medical notation. SOAP stands for Subjective, Objective, Assessment, and Plan, designed to ensure that providers record the following types of relevant details:
- Subjective: Notes about the client’s description of their chief complaint, as well as any relevant details they add about their additional symptoms, feelings, and history.
- Objective: Notes about concrete details the therapist observes, such as a client’s behavior, posture, speech patterns, and vital signs. This section might also include relevant information from patient records, such as toxicology screening results or prior diagnoses.
- Assessment: Notes indicating the therapist’s analysis of the patient’s mental state, history, and behavior. Though this doesn’t necessarily constitute a formal diagnosis, it may include the treatment provider’s thoughts about conditions that appear to fit the individual’s symptoms.
- Plan: Notes outlining the future course of treatment, including next steps and long-term goals — especially those agreed on by the client and therapist. Planning notes might also include discussions of progress or setbacks since the previous session.
What do therapists pay attention to?
During sessions, therapists pay attention to many different indicators that can offer insights into a client’s mental health status and guide their treatment, including:
- Self-reported thoughts, feelings, and behaviors
- Topics that a client brings up frequently
- Non-verbal cues like gestures, posture, and facial expression
- Tone of voice and speech patterns
- Habitual ways of thinking
- Shifts in emotion
- Issues the patient avoids discussing
- A client’s hygiene and personal presentation
Though therapists may not necessarily write all of these details down, they will likely keep them in mind when preparing their notes.
Is it OK to record therapy sessions?
The legality of recording a therapy session may vary from state to state. However, it’s often best to ensure that both you and your therapist feel comfortable about taking a recording beforehand. Doing so without obtaining consent could constitute a major breach of trust that might derail the course of treatment if discovered. It might also place you in legal trouble.
You can certainly ask your therapist whether they mind if you create a recording of your conversations. Surveys suggest that mental health professionals’ attitudes toward this practice are mixed, but many are open to the idea. If you’re certain that you want to record your sessions, but your therapist is uncomfortable with it, it may be best to find a different treatment provider. Alternatively, you could explore possible compromises, such as given ways to session notes.
What do therapists write down during sessions?
The details of what therapists write down during sessions are a matter of personal preference. In-session notes are typically used as memory aids to help a practitioner recall important details when making diagnoses or developing a treatment plan. As a result, they’re often fairly brief and perfunctory.
A therapist may expand on their in-session notes later to create a more detailed record. This is not always the case, though, especially since growing concerns about safety may make it problematic to maintain in-depth session notes. The American Psychological Association has suggested that mental health professionals might be better off limiting their notes to details that are essential for treatment purposes, thus reducing the risk of violations due to things like subpoenas or information breaches.
Do therapists think about their clients between sessions?
Many therapists do think about their clients even when they’re not engaged in therapy. They may turn over details of particular cases during their free time, or have unexpected insights while their minds wander.
Thinking too much about clients between sessions — especially those experiencing difficulty with therapy — may be a source of distress for some therapists. It’s often important for mental health professionals to find ways to limit how much their work encroaches on their free time. However, this experience isn’t universal, and other treatment providers may think about clients mostly when reviewing or preparing for sessions.
Do therapists keep their notes?
Most therapists will retain at least some of their therapy notes following treatment. In some states, this may be legally mandated — seven years is a common requirement. Other jurisdictions don’t have this requirement, but care providers may still choose to retain records in case of legal issues, to be used in possible future consultations with past patients, or simply for their own reference and professional development. Most providers will discard notes after a long enough time, though with the rise of digital record-keeping, some may retain them indefinitely.
What do therapists look for in body language?
Body language can tell an observant therapist a great deal about a patient’s mental and emotional state. They may begin by looking for possible signs of distress, such as hunched shoulders or avoidance of eye contact. This can help a therapist identify topics with strong emotional relevance to the client.
Other possible signals could include things like an open or closed posture, or indicators of relaxation vs. tension. These cues might help assess a client’s mood, such as hinting at whether they’re feeling safe or vulnerable.
Certain kinds of body language may have direct diagnostic value. For example, “self-stimulating” behaviors such as rocking back and forth could point toward conditions such as autism or ADHD.
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