What Is The Purpose Of Therapists Notes?

Medically reviewed by Andrea Brant, LMHC
Updated November 21, 2023by BetterHelp Editorial Team

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.

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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

One of the reasons behind therapy notes is documenting the symptoms or concerns that a client is facing. The longevity, regularity and nature of various symptoms can be essential test info for therapists to be aware of—and progress notes may be added to the patient’s medical record in whatever management software a practice uses. In certain professional circles, this may be referred to as the symptom history. As therapists often have multiple clients, having a record of symptoms could allow them to avoid mix-ups or confusion. Additionally, many practice management software options allow for seamless and discreet transfer of progress note content in their note templates—which can be useful if the client ever needs to transition to a new practitioner.

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.

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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 thoughts or urges of suicide, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or text 988 to talk to someone over SMS. They are available 24/7 to offer support.

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 Therapist 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.  

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Can I Ask My Therapist 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.

Do Therapists 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.

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