A classic debate among therapists is how best to write mental health progress notes. Some prefer keeping their records heavily detailed while others provide only the essential information. Each approach has its own strengths and weaknesses. So how do you choose what’s best for your practice?
Here are 3 things to consider when writing mental health progress notes.
1. Know what’s required
Before deciding how much detail to include in your mental health progress notes, make sure you know what's required.
These notes need to be compliant with state and federal laws, meet third-party contract requirements, document quality care and decision-making for high-risk situations, allow for collaboration with other professionals, and follow the requirements of your treatment setting. This can vary widely between, say, disaster relief counseling in Oklahoma and long-term psychoanalysis in New York.
To learn what's required for your progress notes, check out:
- Your insurance provider's criteria
- American Psychological Association's (APA) Record Keeping Guidelines
- Your state's record keeping laws (likely found on the state's government website)
- Your specific institution's policies
- Any third-party contract(s) you signed
2. Consider the client’s wishes
Some clients may ask you to keep minimal detail in their records. They may be trying to restrict information from interested parties or avoid the possibility of legal trouble down the road. Regardless of the reason, the level of detail you include in their records walks a fine line between protecting you as the treatment provider in the event of an audit or subpoena and protecting them from potential harm. So make sure you have a discussion with the client beforehand to determine if you can meet their request while still being able to provide or coordinate necessary treatment.
One way to honor a client's request for privacy is by using psychotherapy notes (referred to as process notes in TherapyNotes™). These notes allow you to document and analyze conversations with clients separate from the rest of their medical record. This way you can keep your progress notes minimal like your client wants while having additional notes just for yourself. TherapyNotes™ provides easy-to-use templates for both kinds of patient notes.
3. Be specific
No matter how detailed you decide to make your progress notes, it’s always helpful to be specific.
So, instead of writing something like “client was depressed,” consider listing specific symptoms, like “poor appetite” or “sleep disturbances.” This keeps your notes based more in facts than interpretation, which gives them more weight in court and with licensing boards and professional organizations. Another way to protect yourself legally is documenting unusual struggles, dilemmas, and high-risk situations, as well as the steps you took to resolve these issues and your rationale for doing so.
Being specific also helps when working with other clinicians who will make decisions about your patient's care. For example, if you're ordering a certain medication for your client, simply saying they need it may not be enough justification for another clinician to grant the request. But if you list a client's symptoms and write verbatim what they say about their experiences with certain medications, you're more likely to get the treatment your client needs.
These are just a few things to keep in mind when writing mental health progress notes. Check out the APA guidelines for more considerations and our blog on complete documentation to learn about an easier way to take notes.* The content of this post is intended to serve as general advice and information. It is not to be taken as legal advice and may not account for all rules and regulations in every jurisdiction. For legal advice, please contact an attorney.