Understanding Psychotherapy Notes and PHI

When documenting therapy sessions, it’s essential to understand the differences between progress notes and psychotherapy notes (often also referred to as process notes). While progress notes are structured records that form part of a client’s official medical history, psychotherapy notes are private, therapist-only reflections. They can include personal insights, emotional reactions, and observations from the session — helping you process and improve your clinical work.

Unlike progress notes, psychotherapy notes are not required by law, have no standardized format, and are not shared with clients or insurers. They are protected more strictly under HIPAA, particularly concerning PHI in Psychotherapy Notes.

What is PHI in Psychotherapy Notes?

PHI (Protected Health Information) refers to any data that can identify a client and is generated or used during the provision of care. Examples include names, addresses, birth dates, phone numbers, social security numbers, and more. Under HIPAA, psychotherapy notes should contain limited or no PHI, since these are meant to be private therapeutic reflections, not part of the medical record.

Including identifiable information can create legal vulnerabilities. Always consider minimizing PHI in psychotherapy notes to maintain confidentiality and comply with federal regulations.

According to the Department of Health and Human Services, there are various potential identifiers of PHI, which include:

Name
Geographic divisions that are smaller than a state
Phone numbers
Fax numbers
Dates associated with a client (ex: date of birth, admission, discharge, etc.)
Medical record numbers
Health plan beneficiary numbers
E-mail addresses
Certificate/License numbers
Photos (Including full-face photos)
Biometric identifiers (such as fingerprints)
Zip codes
Vehicle identifiers
URL’s
Social security numbers
Account numbers
Device identifiers and serial numbers
IP addresses

HIPAA Regulations and Psychotherapy Notes

HIPAA recognizes that psychotherapy notes are unique in nature — they often contain deeply personal reflections from the therapist and are typically not necessary for treatment or billing. That’s why HIPAA enforces extra protections on them.

According to the HIPAA Privacy Rule:

“Psychotherapy notes” means notes recorded by a mental health professional that document or analyze the content of conversations during private or group counseling sessions. These notes must be kept separate from the individual’s medical record and do not include treatment plans, test results, session times, or medication details.

To release psychotherapy notes, you must have explicit client authorization, except in specific legal scenarios like abuse reporting or imminent harm disclosures.

What Information to Include in Psychotherapy Notes

Psychotherapy notes are private, clinician-focused entries created to support the therapist’s own understanding and development. These notes might include personal reflections, impressions of the client, or questions you intend to raise during supervision or consultation. They are not meant to document treatment plans, progress, or clinical decisions. Rather, they exist solely for your own use and are not part of the client’s official health record.

You may choose to jot down ideas to revisit later, record details that might require professional consultation, or highlight areas where you’d like to expand your clinical knowledge. These notes help deepen your therapeutic insight and enhance your ability to serve your clients more effectively.

When creating what are often called process notes, the focus shifts away from treatment outcomes and toward your internal experience as a clinician. For instance, if a session stirs strong emotional responses in you, it may be inappropriate to include those feelings in the formal chart. Instead, you can record them in a process note for later reflection or supervisory discussion. There is no standardized format for these notes — many clinicians approach them like journaling, freely documenting thoughts, emotional reactions, and observations.

Because of the potential legal implications, some experts recommend writing these notes in a de-identified manner, leaving out PHI (Protected Health Information) whenever possible. While psychotherapy notes are protected under HIPAA, courts can sometimes compel their release under specific circumstances, such as legal investigations or safety concerns.

If you're ever uncertain about what is appropriate to include in psychotherapy notes, it’s wise to seek guidance — whether from your supervisor, your licensing board, or your professional liability insurer.

These notes should support your therapeutic process, not serve as a factual record of care. They’re a space to reflect on countertransference, emotional responses, or interpersonal dynamics that aren’t appropriate for the client’s official chart.

💡 Tip: Keep these notes anonymized and securely stored, minimizing the use of PHI wherever possible.

What to Not Include in Psychotherapy Notes

It’s equally important to understand what to not include in psychotherapy notes. Since they are not part of the client’s medical file, avoid adding any content that falls under medical treatment or administrative documentation.

Excluded Information:

Medication prescription and monitoring
Start and stop times of psychotherapy sessions
Treatment modalities used
Results of any clinical tests or assessments
Diagnosis
Functional status
Treatment plan
Prognosis
Symptom description
Any overview of the client’s progress
Treatment summaries

All of the above belong in progress notes, which are designed for clinical coordination, treatment documentation, and insurance purposes.

The Bottom Line

Psychotherapy notes are entirely optional — they are written solely for the benefit of the therapist. There’s no mandated structure, and they should always be stored separately from a client’s medical record. What makes these notes valuable is the freedom to reflect, explore emotional nuances, and refine your approach to therapy.

But remember: these notes fall under strict HIPAA protections, especially when it comes to PHI in Psychotherapy Notes. To avoid risk, keep them private, de-identified when possible, and never share them without legal obligation or client consent.

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FAQs

1. What information is not included in PHI?

Psychotherapy notes are considered part of Protected Health Information (PHI), but specific administrative or clinical details are excluded from these notes. Information such as medication prescriptions, session start and stop times, treatment modalities, test results, and summaries of diagnosis, functional status, treatment plans, or patient progress are not included in psychotherapy notes and are instead documented in the patient’s medical record or progress notes.

2. What information would not be found on a psychotherapy note?

Psychotherapy notes do not include:
Medication information (prescriptions, dosages, etc.)
Session start and stop times
Treatment modalities and frequencies
Clinical test results
Summaries of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress

These elements are considered part of the general medical record or progress notes, not the private psychotherapy notes.

3. What not to include in therapy notes?

In therapy (psychotherapy) notes, do not include:

Medication prescriptions or management details
Start and stop times of sessions
Types and frequency of therapy used
Psychological or clinical test results
Summaries related to diagnosis, treatment plans, prognosis, or patient progress

These belong in progress notes or the official medical record.

4. What needs to be included in psychotherapy notes?

Psychotherapy notes should include:

Therapist's observations: Patient behavior, tone, and expressions during sessions
Personal impressions: The therapist’s interpretations and feelings about the session
Supervision or consultation questions: Notes the therapist may need to discuss with a supervisor
Hypotheses about the patient: Working theories on the patient’s condition or therapeutic needs

These notes are intended for the therapist’s use and are distinct from progress notes, which are part of the clinical medical record.

5.What are psychotherapy notes according to HIPAA?

Psychotherapy notes, as defined by HIPAA, are the therapist's personal records of a counseling session. They are kept separate from the rest of the patient’s medical record and include sensitive, confidential information such as the therapist’s observations, personal impressions, and details needed for supervision or consultation.

6. How are psychotherapy notes different from progress notes?

Psychotherapy notes are private and for the therapist’s use only, not shared with others without explicit patient consent. In contrast, progress notes are part of the official medical record and include clinical information such as diagnosis, treatment plans, progress, and care coordination details.

7. What should be included in psychotherapy notes?

Psychotherapy notes should contain:

Therapist’s observations: Notes on the patient’s demeanor, behavior, and verbal interactions
Personal impressions: The therapist’s insights, interpretations, and feelings about the session
Questions for supervision or consultation: Topics the therapist needs help with
Hypotheses about the patient: Working theories or conceptualizations guiding the treatment

8. What should be excluded from psychotherapy notes?

The following should not be included in psychotherapy notes:

Medication information:

Prescriptions and dosage details
Session start and stop times
Treatment modalities and frequency
Clinical test results
Summaries of diagnosis, treatment plan, prognosis, and functional status

These should instead be documented in the progress notes or the medical record.

9. Why are psychotherapy notes kept separate from the medical record?

Psychotherapy notes are kept separate to protect the privacy of the therapist’s personal impressions and sensitive clinical observations, and to encourage candid therapeutic reflection. Their confidentiality is more tightly protected under HIPAA compared to general medical information.

Sources:

U.S. Department of Health and Human Services. (2022). Guidance Regarding Methods for De-Identification of Protected Health Information in Accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. https://www.hhs.gov/hipaa/for-professionals/privacy/special-topics/de-identification/index.html#protected

Office for Civil Rights (OCR). (2017). Does HIPAA Provide Extra Protections for Mental Health Information compared with Other Health Information? https://www.hhs.gov/hipaa/for-professionals/faq/2088/does-hipaa-provide-extra-protections-mental-health-information-compared-other-health.html

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