What's the Difference Between Therapy Progress Notes and Process Notes?

Being a therapist isn’t only about connecting with your clients during sessions. There’s also important and necessary paperwork involved to keep your practice compliant and running like a well-oiled machine. 

Are you ever confused about the difference between a progress note for therapy and a process note for therapy?

There’s no need to be embarrassed - with so many of our “parts” at play during session, therapists get fuzzy on the distinction all the time. 

And if the administrative side of note taking for therapy isn’t your forte, we’re here to help, beginning with answering a simple question — what's the difference between a progress note and a process note?

The Importance of Record-Keeping

Good record-keeping benefits both you and your clients — with clear documentation about your client’s history and care, you can plan, record, and evaluate treatment to better serve them. 

Timely and appropriate record-keeping also protects you and your practice from potential risk of liability. 

It’s also important to know how privacy regulations affect the two, very different types of notes.

Psychotherapy Progress Notes vs Process Notes Defined

Psychotherapy Progress Notes

Progress notes are confidential records of a patient’s treatment and treatment response. They can include information on a patient’s medical history, symptoms, diagnosis, test results, treatment plan, prescription medications, progress throughout sessions, and more. 

They can serve a variety of purposes:

• Helping other mental health or medical professionals  keep up with your work with a client
• Informing insurance companies about the reliability and effectiveness of your treatment
• Protecting your practice if someone questions the quality of care

Psychotherapy Process Notes

On the other hand, psychotherapy notes (also called process notes, therapy notes, or private notes) are meant for your eyes alone. They’re a private record of your own thoughts, feelings, and impressions regarding what happens throughout treatment. 

In short, progress notes are meant to be shared when requested, while process notes are more a reflection of your thoughts and feelings about a particular client interaction.

How HIPAA and Privacy Regulations Affect Your Therapy Process Notes

Under HIPAA, your psychotherapy notes are protected due to the sensitive information contained and their personal nature. 

You’re obligated to prevent access to them by keeping them separate from your progress notes. If you don’t, others could gain unauthorized access which is a breach of client privacy. 

If the situation calls for it (e.g. court order, a grand jury subpoena, administrative requests from government agencies, or similar legal requests), you can only release your therapy notes with your client’s written consent on a specialized form. 

Your progress notes, on the other hand, can be released either without your client’s consent or with generalized consent.

What is the Difference Between Therapy Progress and Process Notes?

To sum it up, what's the difference between a progress note and a process note? 

Progress notes record information about your client’s treatment, including session schedules, test results, diagnosis, treatment progress, and so on. They can be released to other healthcare providers with generalized consent from your client. 

Process notes, also called psychotherapy notes, are more personal and confidential. They’re a record of your personal observations during sessions and must be kept separate from progress notes. They can only be shared in specific circumstances and require express written consent from your client.

What Are “Clinical Notes”?

This is another term you may have heard thrown about. “Clinical notes” is a much broader category of patient records, including progress notes from each session, treatment planning, and intake information. 

It essentially includes everything except therapy process notes, and you can treat progress notes as a subset of it. Progress notes for therapy report on individual sessions, while clinical notes offer a more comprehensive look at the patient’s overall situation.

Ready to create therapy progress notes with ease?

If writing progress notes from scratch feels like a chore, you’ll definitely want to explore our point-and-click note generator, Clarity Notes. 

Our customizable tool allows you to pick from our comprehensive templates and lists of interventions to create progress notes quickly and without the hassle. 

As therapists, we set out to improve upon the existing note generator tools we’d been using for years.  

Unlike other tools, you can create, save, and re-order your own custom phrases so  that you can easily access your most frequently used interventions and modalities each time you create a new note. After all, why should you have to scroll or tab through lists of interventions and modalities that don’t apply to you and your work? Save yourself precious time that could be spent doing something else more fulfilling.

Are you ready to simplify the way you create progress notes? 

[Get Clarity Notes]