Most therapists keep some form of notes to record patient encounters, keep track of important information, and monitor progress. Therapists who contract with insurance companies must write notes documenting each session.
What should be included in a therapy note, and how do you balance confidentiality with the need for accurate record-keeping? While there is some variation in how therapists keep and use notes, there are also standards and legal considerations to keep in mind when writing therapy notes.
The field of psychology loves acronyms, and “SOAP” notes are a prime example. Each of the four letters in the word SOAP corresponds to a type of information that should be included in a therapy note: subjective, objective, assessment, and plan. The SOAP template helps the therapist to distill a 45-minute session into the most essential facts, keeping notes concise and professional.
Subjective– Subjective refers to information that the patient shares directly. It could be an account of their mood, functioning, or a significant event that occurred. To protect confidentiality, it is best to avoid quoting the patient directly. Instead, summarize their report using clear and concise language.
Example: Patient-reported low energy and difficulty concentrating this week.
Objective– Objective refers to factual information about the client’s appearance, mood, behavior, or orientation. This is not your opinion about how the patient is doing (you’ll be able to provide that in the “assessment” section), but facts that can be directly observed and/or verified.
Example: Patient appeared disheveled, with shirt untucked and hair uncombed, and spoke rapidly throughout the session, often jumping from one topic to another.
Assessment– Here, you provide your clinical impressions and interpretation of the subjective and objective information you just summarized. Include information about the patient’s symptoms and possible diagnosis.
Example: The patient presents with symptoms of mania and depression, indicating possible bipolar disorder.
Plan– What should the patient work on between now and the next session? Remark on any changes to the treatment plan or progress toward treatment goals.
Example: The patient agreed to reach out to their sister and brother-in-law for social support and will likely need a referral for a psychopharmacological assessment.
Therapist notes vs. progress notes
Many therapists keep notes for personal reference in addition to the progress notes that are required by insurance companies. These therapist notes are primarily to help the therapist remember information important to the treatment relationship but not appropriate for SOAP notes. For example, you may want to jot down the first names of patients’ family members and significant others or a few details about their employment history. While progress notes can be audited by insurance companies or subpoenaed for a legal investigation, therapist notes are private and are read only by the therapist. As such, they need not follow any particular format or make sense to anyone but the therapist. However, HIPPA requires that therapist notes be kept separate from progress notes.
HIPPA requires that all patient records, including both progress and therapist notes, be kept secure and confidential. This means that paper files should be kept in a locked file cabinet in a locked office, and electronic files should be password protected and/or encrypted. Any disclosure of this information to a third party must be authorized by the patient in writing, with a few exceptions.
Situations in which you might be required to share your progress notes include the following*:
- The notes include information referencing the threat of harm to self or others.
- You receive a court order for treatment records and/or testimony.
- The notes include information about abuse or other topics covered under mandatory reporting laws.
*Note that this is not an exhaustive list, and regulations vary from state to state, so make sure to familiarize yourself with the policies in your state.
Therapy notes are an important piece of providing quality care for patients. They help therapists to conceptualize cases and remember where they left off from session to session. Therapy notes also document the services therapists provide, including risk assessment and crisis intervention. If you are audited or your clinical judgment is questioned by a third party, therapy notes can be valuable records of due diligence.