Therapy notes, on the other hand, need not make sense to anyone but the clinician. They must contain certain information in orderly formatting so other providers and insurance companies can easily use them. One of the biggest differences between therapy notes and progress notes is the standard placed on progress notes. Main Difference Between Therapy Notes and Progress Notes In other words, progress notes are a subset of clinical notes they report results of individual appointments, while “clinical notes” include comprehensive patient records. The broader term “clinical notes” includes all of a patient’s records (aside from therapy notes), including intake information, big-picture treatment planning, and the progress notes from each clinical encounter. While many use these two terms interchangeably, there is a technical difference. Are “Clinical Notes” the Same as Progress Notes? Others who may access progress notes include the patient and their family members.Īs with therapy notes, certain legal scenarios may compel you to share progress notes with a wider audience, such as before a court of law or during an HHS investigation. They can also protect you if questions arise about quality of care. Progress notes help other practitioners or treating physicians stay up-to-speed on your work with a patient, and they inform insurance companies of the reliability and efficacy of your methods. This covers information such as diagnosis, symptoms, medical history, test results, treatment plan, progress at appointments, prescription medications, etc. Progress notes, on the other hand, record information relevant to the patient’s treatment and response to treatment. Therapy notes are private records meant to help therapists remember patient encounters. The Difference Between Therapy Notes and Progress Notes Department of Health and Human Services (HHS) requests them as part of an investigation A coroner or medical examiner requests them as part of an investigation.The notes contain information regarding abuse or other topics covered under mandatory reporting laws.You receive a court order for documents and/or testimony (state laws may vary).involves the threat of harm to self or others They contain information that falls under your “duty to warn,” i.e.You might have to share your therapy notes if: The following is not an exhaustive list and state laws may apply, so check regulations in your state. Are you ever required to share therapy notes?Ī variety of situations may legally require you to share therapy notes. Something as simple as a locked filing cabinet or password-protected computer will do the trick.Ĭlinicians may keep therapy notes about everyone they treat, whether individuals, families, or groups. They can be written longhand or stored digitally as long as the therapist is the only one with access to them. HIPAA regulates that therapy notes be stored separately from progress notes. Notes that contain a therapist’s private impressions and interpretations of patient conversations may contain information that would not benefit the patient. In fact, providers whose patients request these notes may want to think long and hard about granting the request. Practitioners aren’t even required to share them with patients themselves. They don’t appear in medical records and cannot be shared with a third party except by the patient’s written consent. These notes naturally contain sensitive information, and are kept confidential. A clinician might record their thoughts, impressions, and feelings about the conversation, along with important details and topics they want to pursue next time. Also called psychotherapy notes, these records help the provider keep track of what happened at each appointment. Therapy notes are a clinician’s private record of their patient encounters. What’s the difference between them, and is your practice compliant with the privacy regulations for each type?įailing to follow best practices for therapy notes and progress notes can have legal and professional repercussions. Therapy notes, progress notes, clinical notes-you may have heard these terms thrown around interchangeably.
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