The requirements for documenting your client sessions are not specific to the setting, but agencies often follow guidelines set by third party funders. These guidelines may not be applicable to your private practice internship if you are not billing a third party insurer.
Before directly addressing the specific requirements of documenting sessions with progress notes, I’ll review the reasons for keeping progress notes when your client is paying directly for treatment. Under the Health Insurance Portability and Accountability Act (HIPAA), each client is entitled to receive a copy of her/his treatment record on request and you are obligated to provide one if requested.
Client records might also be requested, with the client’s permission, by another health care provider, by an administrative organization evaluating your client’s application for assistance (for example, Social Security Disability Income, which you can learn more about via social security disability law), or by an attorney in a lawsuit brought by your client claiming damages for emotional distress. A client record would also be required if you need to respond to a complaint or lawsuit filed by a client against you. You may believe that all of these situations are unlikely to occur with your private practice clients, but being without an adequate record could place you at some degree of risk or could create a complication for your client. You might not release the full record in some of these situations, but you would need a record in order to respond to the request.
Let’s return now to the issue of requirements for progress notes. All aspects of the treatment you provide are measured against the professional standard of care. The standard of care is the generally accepted practice used by other professionals providing a similar service. The codes of ethics of the professional associations for psychologists, marriage and family therapists, and social workers state that clinicians should keep accurate records documenting their work, without specifying the content of those records. Therefore, keeping progress notes for psychotherapy sessions is the standard of care.
There are several methods you can use to guide you in writing progress notes in a private practice setting. First, I would suggest asking your supervisor for her/his standards for the format and content of progress notes. If your supervisor doesn’t have a specific format, you could adapt the format you used at your agency internship to fit your private practice. You can also check with colleagues and your local or state professional association for templates used by other therapists.
Two resources you can check in print or online are the American Psychological Association Record Keeping Guidelines and a book by Donald Wiger entitled “The Psychotherapy Documentation Primer” published by John Wiley & Sons in 2012. These resources contain a list of the information that should be included in a progress note for each service provided. To summarize, the most important elements to include in a progress note for a psychotherapy session are: the context of the session (date, time, length, who attended, location, service provided), status of the client’s symptoms and functioning, any assessment you conducted and the actions taken as a result of the assessment, interventions provided, plan for future treatment, and your signature including your licensure status and date signed. You probably also need to include some narrative description of the topics covered in the session.
One additional issue to keep in mind is that HIPAA defines psychotherapy notes as distinct from progress notes. Psychotherapy notes are kept by you for your own analysis and may contain conjecture, inference, judgments and emotionally charged material. Psychotherapy notes are not part of the official treatment record and do not have to be released to the client or other parties. Progress notes should be factual and objective in describing your observations and interventions without the more subjective material that can be kept in a psychotherapy note.
I hope you found this information helpful in writing progress notes in a private practice internship. Please email me with comments, questions or suggestions for future blog topics.