Process Notes vs Progress Notes: Psychotherapy Notes Under HIPAA

Progress notes are the official clinical record of a session: dates, interventions, symptoms, diagnosis, treatment plan and progress. Process notes, which HIPAA calls psychotherapy notes, are a therapist's separate notes analyzing the conversation in a session. Psychotherapy notes get extra privacy protection under HIPAA, but only if they are kept separate from the rest of the record.

The terms are used loosely in practice, so it helps to start from the legal text. The HIPAA Privacy Rule defines psychotherapy notes in 45 CFR 164.501, and HHS explains the rule in its FAQ on mental health information. This guide summarizes both. It is general information, not legal advice; state law and your licensing board may add requirements.

Under 45 CFR 164.501, psychotherapy notes are notes recorded in any medium by 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 individual's medical record."

The same definition lists what psychotherapy notes exclude. None of the following can be a psychotherapy note, wherever you write it:

• Medication prescription and monitoring
• Counseling session start and stop times
• The modalities and frequencies of treatment furnished
• Results of clinical tests
• Any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date

In other words, the content of an ordinary progress note is, by definition, not a psychotherapy note. HHS adds that psychotherapy notes "also do not include any information that is maintained in a patient's medical record."

HHS explains that, with few exceptions, the Privacy Rule requires a covered entity to get the patient's authorization before disclosing psychotherapy notes for any reason, "including a disclosure for treatment purposes to a health care provider other than the originator of the notes." The rule is at 45 CFR 164.508(a)(2).

HHS names a notable exception for disclosures required by other law, such as mandatory reporting of abuse and mandatory duty-to-warn situations involving threats of serious and imminent harm. State laws differ on whether such a warning is mandatory or permitted.

Separately, 45 CFR 164.524(a)(1)(i) excludes psychotherapy notes from an individual's HIPAA right to inspect and copy their records. Progress notes are not excluded. State law may still give clients broader access, so check your state's rules.

The same fictional session, documented both ways:

Notice that the psychotherapy note contains no times, scores, diagnosis, plan or progress summary. Those belong in the progress note, which is the document your payer, a colleague or an auditor will read.

The protection depends on separation, so make it visible in how you work:

• Use a different place. If your EHR has a dedicated psychotherapy notes area that is excluded from the chart and from record releases, use it. Otherwise keep them in a separate, secured file, not in a progress note field.
• Label them. Mark the document as psychotherapy notes so staff handling a records request know to treat it differently.
• Keep required content out. Session times, scores, diagnosis, interventions delivered, risk assessment and plan go in the progress note, every time.
• Write them for yourself. Hypotheses, reactions and questions for supervision, in language you would be comfortable defending if a law ever required disclosure.
• Check your setting's policy. Agencies, training programs and states differ on whether and how psychotherapy notes are kept and how long they are retained.

The HIPAA rules on psychotherapy notes describe how such notes are protected when a clinician keeps them. HHS describes them as personal notes of the therapist that typically are not needed for treatment, payment or operations other than by the clinician who wrote them. Many clinicians keep none and put everything clinically relevant into the progress note. Others keep brief process notes for supervision or case formulation.

If you keep them, keep them physically or electronically separate from the record, and do not copy their content into progress notes. For the progress note itself, our guide to therapy progress notes examples and templates and the SOAP, DAP and BIRP templates show what a complete note includes.

WellNotes drafts progress notes in formats such as SOAP, DAP and BIRP from a short summary you type or dictate after the session. Saved notes stay in your browser rather than on WellNotes servers, so copy the final note into your EHR or records system.