Complete a Psychotherapy Note

While Progress Notes in TherapyNotes feature robust templates to ensure that your notes are organized, clear, and complete, the Psychotherapy Note is a free-text note that functions differently than a Progress Note. HIPAA has a specific definition for psychotherapy notes, which are what TherapyNotes refers to as Psychotherapy Notes:

"Psychotherapy notes” means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

Role Required: Clinician, or Clinical Administrator

Tip: Psychotherapy Notes are not billable, and should contain different information than a billable Progress Note.

To Create a Process Note:

Click Patients > Patient name > Documents tab
Click the Create Note button.
From the list that appears, select Psychotherapy Note
Select a recent appointment, or click Create Note for an Unscheduled Appointment

To learn more about creating notes and note writing tools in TherapyNotes, read Create a Note.

Note Header

The note header automatically fills in information for the clinician, client, and appointment. To edit information in the note header such as the Note Title or date and time of the appointment, click anywhere on the note header or click Edit in the upper right corner.

Note Content

Process note field

Note Content is blank text field with no limit to the number of characters you can enter. Use this field for any notes related to the session.

Tip: For future Psychotherapy Notes, click the History button > Use to pull the text forward and keep your template consistent.

Save Your Note

Note: In order to save a Psychotherapy Note, you must complete the Psychotherapy Note field.

Save process note

Once you have completed your Consultation Note, click the Create Note button. There is no need to sign the note, as you would a Progress Note

Keeping Process Notes Separate from the Clinical Record

HIPAA requires that psychotherapy notes be kept separate from the remainder of the clinical record. They also cannot be disclosed without the express authorization from the client except in very limited circumstances. Psychotherapy notes are even exempted from the client's right of access to their record. TherapyNotes makes this easy to do. When you download notes from a client chart, you have the ability to select all notes in their record at once. If the client has any Process Notes, you will see a warning:

Deselect process notes for download

Click the Deselect Psychotherapy Notes link to remove all Psychotherapy Notes from your selection, then click the Download Selected Documents button to get a PDF of all the selected notes.