Write Better Therapy Notes: Tips from a psychologist who reads them for Court

If you'd rather see this in a video, click here:

Who am I and what do I know about it?

I'm a board certified forensic psychologist. I request and review progress notes for a living. I've read hundreds of thousands of pages of medical and therapy records over the course of my career. I've consulted with many clinicians about this issue and often hear the same thing: no one really trained us in doing this in the real world. The following is a rubric to help give you some grounding about what to do, and what not to do, to protect yourselves and your clients.

I am not a lawyer. I am not a malpractice specialist. You can take this information and use your own judgement about it, or not :) 

What is the bottom line?

Most therapists write way too much in their notes, and instead of fixing that problem, they instead (inadvertently) break the law by withholding records to try and protect patient privacy.

What am I doing wrong?

If you are a person who is worried about releasing your progress notes, chances are that you're writing too much. 

If you always respond to records requests by offering a summary instead of the requested record, you're probably doing something wrong. 

If you are a person who believes you have broad discretion about what is released, you're definitely doing something wrong. 

This isn't your fault. At least not mostly. 

 If you're anything like me, you got a couple of crash courses in grad school about note writing, maybe a SOAP template or three, but most of your training came from placements. Which means, you're being primarily trained by other therapists and by supervisors who are also doing it wrong. 

And that's how you get to what I like to call therapist lore. Therapist lore - myth - says that therapists are supposed to write "narrative" notes to promote continuity of care, so that the next clinician could pick  right up if you got hit by a bus today. That same therapist lore - myth - says that therapists should field a records request, decide if there is any risk of harm, and then withhold releasing any note that they can imagine might lead to risk of harm to self or others. These myths are patently false. 

The purpose of a progress note is to establish medical necessity. To appropriately document that a professional service took place. And to track client progress as compared to a treatment plan. You need precious little in there to accomplish those goals. We'll get to where you can put that other stuff in a bit. 

For now, let's talk about how therapists can and should take cues from medical notes. Those are typically a few sentences about the service that took place - spoken from an objective viewpoint, and most often from an appropriate distance, somewhere between way up close, and 20 miles away. But therapy is different! In the room, yes. In the chart, no.

What should I do?

Read the rest of this post to find out, and also check out what to do if you get a subpoena. 

Ok, here are the top 6 complaints I hear about suggesting that clinicians write therapy notes like medical notes:

The information covered in therapy is private.

Do you think medical records aren't private? The privacy belongs to the patient/client, not the therapist. Privacy becomes irrelevant at the point there is a valid release of information waiving it. 

The client doesn’t always know that they’re signing an ROI (or what they’re signing).

Are you sure that you understand it better?  Unless you also work in disability, or school psych, or insurance, or forensics, the average therapist has almost no idea about the specific needs and rules in those areas; you can cause real problems for your client by making decisions about release in arenas you don't understand. If you really feel concerned your client does not understand what they signed, talk to them about it. 

I don’t want this private information out in the world.

Why do you think that is your decision? There is an old model of therapy that many therapists still buy into, though I think it happens more inadvertently these days. And that is a parentification of clients, treating them as highly fragile and vulnerable. Maybe that was true 20 years ago, when therapy was more stigmatized so that things had to be real bad before someone was willing or able to get treatment. And it's still true for select segments of the population. But by and large, people are capable of making their own choices, as long as there is informed consent. They can weigh risks and benefits, and they can deal with fallout. Also, the people you are sending info to, by and large, are also bound by privacy regulations. It's not like they're asking you to release it to a restroom in a truck stop (but even if they were, you would probably still need to). 

Releasing the information may cause harm.

Says who? I am surrounded by therapists - my closest friends and family - so I say this with all the love I can muster. Y'all (ok...we all) are an anxious bunch. Just because you believe a release will result in suicidal thoughts, doesn't mean it will (or doesn't mean those thoughts will come with action). The "harm" provisions for note release stems from very specific, highly unusual one-off situations that are often abused by therapists to justify not releasing notes they are legally obligated to disclose. When in reality, you may redact a portion of the chart if you clearly note that you did so, and provide the recipient with instructions about how to appeal the redaction if they choose to (see Reviewable grounds for denial (45 CFR 164.524(a)(3)).; Carrying Out the Denial 45 CFR 164.524(b)(2); how the individual may submit a complaint to the covered entity or the HHS Office for Civil Rights, CFR 164.524(d), and 45 CFR 164.524(d)(4) Reviewing the Denial). Your justification for doing this should be airtight, most often linked to a clearly identified and specific reason that you believe imminent harm will occur.

There are laws protecting juvenile disclosures.

Do you know what they are? Most jurisdictions have them. In my experience, in most instances where therapists withhold based on this rationale, the laws compelled them to release. This will be jurisdiction specific, but most juvenile consent laws have a very specific set of requirements that have to be met - for example, where I practice they have to be paying for treatment independently. So unless you work in a low/no cost clinic or are doing pro-bono work, in most cases that won't apply. Be very clear what the rules are where you practice if you work with juveniles.

Harm can only come from disclosure, not withholding so it makes sense to be conservative.

 Are you sure? I have seen your clients harmed by refusals to release records out of a misguided effort to protect a client. In one family court case,  I could not substantiate that the parent was appropriately engaged in treatment because the note set I received had fewer notes than the parent indicated they should have across the course of their treatment. I was unable to determine if the parent misled me, or the therapist withheld notes. Which made my opinions much more tenable about that parent's psychological stability. That is just one example - there are others related to disability, special education, and insurance reimbursements. 

What should I be doing instead?

So glad you asked! There are three suggestions you can start doing right now, today, to tighten things up here. 

1. Treat the therapy note like a medical record (because it is).

We fought for parody, and now we have it. That comes with certain responsibilities, too. We have to substantiate to insurance that there is a need for, and benefit from, treatment. We have to talk more about symptoms, and less about stories. More about interventions, and less about feelings. It's not a narrative note. It's a few sentences about the service provided, the patient/client response, and the resultant care plan. If you're not sure what medical notes sound like, request your own. Read them, and use them like a rubric for your sessions. 

2. Visualize exposure.

I mean it. Literally imagine your note becoming a part of the record in the nastiest custody situation. A civil lawsuit over millions. A high-profile criminal trial. Then write from that position. It will push you towards two things that the best medical notes already do:

Brevity. A few sentences. There just isn't much room to violate your client's privacy or overshare. 

Objectivity. You're trained, for the most part, not to be objective in the room. That's ok. Let empathy rule the day in the room. But write your notes more like a robot. Your thoughts and feelings are less relevant than your sense observations (I know, robots don't have senses. The analogy fell apart quickly here...). If you ever get to Court as a fact witness, those sense observations are what you can testify to. What you saw and heard, primarily. Writing almost exclusively about those things helps keep you on point and out of the weeds emotionally. 

3. Use the psychotherapy note loophole. 

It's the greatest gift ever. And in most EHRs these days, it's a simple matter of scrolling down a little farther to get to that safe, warm box that doesn't count as part of the chart. Get in the habit of putting anything non-factual, for your own memory, or so sensitive you'd cringe if it were released, tucked away in there. 

Conclusions

The world is moving towards real-time chart access for clients to have more autonomy over their records. Therapists need to get on board with these trends by writing notes more conservatively, and then with less obstructionism when those records are requested. The best way to protect both yourself and your clients is to write brief, objective notes that you would be comfortable reading aloud in a crowded Courtroom, if push came to shove. If you want some examples, keep scrolling...

Client was on time and present entire session. Content focused on processing assault allegations. Therapist used reflective listening and cognitive-behavioral techniques to challenge thoughts that client "deserves" bad things happening. Future sessions will continue to work on adjusting this kind of thinking to reduce depressive symptoms. 

Patient discussed ongoing struggles with sobriety in light of a particularly difficult moment this week. Therapist used motivational interviewing techniques to support client's efforts to stay sober. Future sessions will continue to review sobriety maintenance efforts to help client meet his goal of sustained sobriety from alcohol use. 

Client was 15 minutes late to session. We discussed relationship challenges with husband, which have been discussed previously. Therapist challenged client on old thinking patterns in efforts to build accountability and improve self-efficacy, as she has demonstrated in the past that mood symptoms improve when she takes agency for her role in relational dynamics. Next session in 2 weeks. Client will receive reminder 1 day prior to hopefully help attend session on time.

 For more tips, tricks, and forensic musings, please consider following the Streamline blog!

And if you have other ideas about writing better therapy notes, please comment below!