Psychotherapy Notes Policy Term Definition

Notes (i.e., process notes) that capture the therapist’s impressions about the patient containing details of the conversation considered to be inappropriate for the medical record, and are used by the provider for future sessions. Psychotherapy notes can also be recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes are kept separate from the rest of the individual’s medical record. These notes typically exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms and progress to date