September 23, 2019 at 04:08PM by CWC
It happens in most therapy sessions: You sit there, talking about your thoughts and feelings while the professional listening to you scribbles down their own, private machinations that you’re not invited to see. These therapist notes can be highly distracting because not being privy to their contents is liable to make you more curious as to what they contain. Naturally, that raises a big question: What’s in the contents of these notes?
Though the experience of not being able to ignore the note-taking might be common, what exactly the pros are writing tends to vary depending on the specific type of mental health professional you visit, their style, and the headspace you’re in, says psychologist Simon Rego, PsyD. But there are some commonalities in form to speak of.
There are usually two parts of a therapist’s notes, according to clinical psychologist Alicia Clark, PsyD. One is the official client record that documents the date, length of the session, and the diagnoses that were addressed. The other features a therapist’s notes of the process of ongoing treatment, she says. “Therapists’ process notes are to help therapists solidify memories of important details, themes to come back to, or noteworthy elements of the therapy process,” she says. “These small bits of information help us remember where we left off when we meet again and help us track the progress of therapy.”
Generally, therapist notes differ from the client record. “The client record includes the basics of what occurred in session, including interventions that the therapist employed,” says counselor David Klow, LMFT. “Therapist’s notes, however, are private and usually do not go in the client record. They are used for the therapist to keep track of the case and guide their work.” In those notes, a therapist may jot down important information you mention, as well as something they want to come back to but don’t want to interrupt you in the moment, Dr. Rego adds.
“Therapists’ process notes help therapists solidify memories of important details, themes to come back to, or noteworthy elements of the therapy process.” —psychologist Alicia Clark, PsyD
Dr. Clark points out that recording protocol differs across facilities and practices. For instance, if you visit a larger mental-health organization, she says, it’s likely that there’s a structured note-taking policy in place for administrative purposes than if you see someone at a smaller outpatient facility. “Generally, the bigger the facility, the more formal the note-taking protocol,” But, the absence of therapist notes doesn’t necessarily point to any kind of problem with with your regimen. “Not every therapist takes notes during a session,” Dr. Rego says.
If you’re curious about seeing your patient record, know that you’re legally allowed to have access to it. “Patients are entitled to see their official record including session information, diagnosis, treatment plans, structured notes, and diagnostic assessments,” Dr. Clark says. But, because therapists’ process notes are not considered part of the official record, your therapist isn’t required to share them with you, she says.
However, your provider may be just fine with letting you see their notes (if you can read them). “For me, it’s quite transparent,” Dr. Rego says. “I have the file open on the table between us so the patient can review what we last talked about, if they want to. My stance is that it’s their notes. I’m just keeping track.”
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