Therapist Notes In Mental Health Psychotherapy
Many people find themselves feeling intimidated or confused about counseling. You might notice that your therapist uses a notepad or note-taking device during counseling. The use of therapist notes 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.
Therapy notes
Learning about why therapists take notes can be beneficial in understanding the overall treatment process, and the possible range of benefits that a patient can gain from routine practice visits. Read on to learn more.
Why do therapists take therapist 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.
Therapy notes
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 therapist 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.
Therapy session details and patterns
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.
The patient's mental health
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.
Areas for therapy session improvement
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.
Do all therapists take therapy notes?
Some therapists might opt out of note taking 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.
Seeing your therapist's notes
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.
Can my therapist show me their therapy notes?
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.
Therapist notes and potential disagreements
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 remember 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.
Mental health therapy 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.
About the study
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 therapy
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 their therapy notes?
Not all therapists write notes during therapy sessions, but many do. The content of such notes can vary based on the individual therapist and the circumstances of the session. Still, some common types of notes may include notes about the client’s concerns and symptoms, ideas and topics for future sessions, reminders about clinical tests, and appointment details for the next session. Therapy notes are not unlike progress notes a doctor might keep when treating a physical condition. Generally, therapy notes shouldn’t include any identifying information for the sake of discretion.
Can I see the therapy notes?
Yes. You’re within your rights to ask to see your therapist’s notes, and depending on the therapist and your therapeutic relationship, many clinicians may allow you to see them. Still, depending on the laws in your state, they may also be within their rights to keep their notes.
What's TherapyNotes?
TherapyNotes is an online tool used by many mental health professionals during sessions. It can be used to take therapy progress notes, schedule appointments, and bill clients for sessions. In TherapyNotes, the therapist may be able to separate their notes into two broad categories: psychotherapy notes and progress notes.
What body language do therapists look for?
Every therapist is different and might look for different nonverbal cues. Still, most clinicians will look for microexpressions, posture, eye contact, and gestures the client uses. Looking for body language clues can give the mental health professional a fuller picture of the client’s mental health and wellbeing rather than relying on only the verbal aspect of the client’s response.
How to write therapy notes?
There are many different ways to write mental health notes, and each therapist may have a different technique. Generally, it’s a good idea to be as specific as possible when writing therapy notes, including any presenting symptoms and specific examples from the session. The idea is to give the therapist a clearer picture of the session than what they’re able to remember on their own.
What do therapists pay attention to during a session?
There may be many things a therapist pays attention to during a session with a client. These can include observations about the client like a depressed mood or anxious behaviors, for example. Most therapists pay attention to not only what the client says, but what they don’t say as well as any nonverbal cues such as body language. They may also look for signs of a client’s progress from one session to the next to indicate the potential effectiveness of a certain treatment furnished, including treatment modalities or in-session interventions.
Can I record therapy sessions?
No. Without consent from the therapist, it’s not okay to record your therapy sessions, and in some cases, it may be illegal. If you want to record a session for any reason, it’s important to ask for permission first. Likewise, a therapist cannot record a session without the client’s consent.
What do therapists write down during therapy sessions?
A mental healthcare professional such as a therapist may take unique notes depending on their approach to therapy and personal preferences. Still, these notes may include:
- Observations about a client’s mood, behaviors, negative thoughts, and concerns
- Any progress the client has made since the last session
- Questions the therapist wants to ask later or topics for further exploration
- Homework assignments or exercises the therapist recommends
- Psychological tests they want to administer
- Reminders about appointments
- Key themes and quotes from the session
- Ideas on how to improve the therapeutic alliance
- DAP notes (Data, Assessment, and Plan)
- BIRP notes (Behavior, Intervention, Response, and Plan)
Do therapists think about their clients between therapy sessions?
It depends on the individual therapist, but generally, yes. Therapists may use time between sessions to reflect on a client’s progress and how they can better serve them in a professional capacity.
Do therapists keep their therapy notes?
Yes. Therapists usually keep their notes, but according to the U.S. Department of Health and Human Services, these notes are protected by the Health Insurance Portability and Accountability Act along with other medical records like a medication prescription or diagnosis. Its laws ensure these notes cannot be shared with anyone without the client’s permission. One exception is your insurance company. In some cases, the insurance company can request therapy notes to determine coverage for certain treatments. Other service providers will need your signature before they can receive therapy notes, information, or medical records.
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