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Psychotherapy Progress Notes Templates

Knowing how to write psychotherapy progress notes in an efficient, HIPAA-compliant manner is one of the first things that a therapist should do when beginning a private practice. Here are some sample psychotherapy progress notes, some psychotherapy notes software you can use, and some progress note templates you might like. Make sure to protect privacy if you're using electronic psychotherapy progress notes!
9 Pins817 Followers
from QA Prep

The Great Debate: Long v. Short Notes

Long or short notes? It's not about the length. It's about the content.

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The Great Debate: Long v. Short Notes

qaprep.com

from QA Prep

Can't I Just Write Notes on My iPhone?

One of the big things I like to talk about is “de-mystifying the process of documentation.” Every therapist in private practice, and even in most agencies, have a totally different way of writing notes. There’s nothing wrong with that but when we rarely talk about documentation, it becomes a problem.  You see, this means that as therapists we have little framework for what is best practice. Instead, we figure things out as we go along… and sometimes that means we wait a little longer than we should to seek advice. A  while back I met a therapist who asked me what I do. After I explained I help therapists create awesome documentation so they have more time with their clients she laughingly asked if she should be doing more than just writing some notes on her iPhone. I've heard about some pretty crazy things, from being months late on documentation to outright and intentional fraud, but this comment took me aback. She was serious! I told her she needed a file of some sort and should at least document informed consent as soon as possible. She didn't seem to care a whole lot and this shocked me, then made me a little angry. You see, documentation is not some after thought. It is an important piece of the clinical work we do as therapists.  Aside from the CYA part of documentation (which I do think is very important), your paperwork serves to provide continuity of care as well as a time to reflect on the clinical work you're doing. Much of what we do is ambiguous but if we're not able to put it into words, how are we able to describe the work of therapy to new (or doubting) clients?  If you're in private practice you have the freedom to decide how and when you want to write notes. A great way to connect the paperwork to your clinical work is to use documentation as a reflective time as well. Consider 1-2 things that stuck out to you about that session and how does it relate to previous sessions? Does this bring up something you'd like to follow up with during the next session? Is there any countertransference or reaction you need to process on your own or through a consultation group? Write it down, process, follow-up with a colleague or research a topic you may need more knowledge of. This clearly makes documentation a clinical process. I believe this way of writing notes will make you a better therapist and keep you growing professionally. It also makes the act of documentation less of a chore. If you're interested in more tools to make documentation easier and see how it can make you a better clinician, sign up for my monthly newsletter and the free Private Practice Paperwork Crash Course. And feel free to comment below with any tips you have for making paperwork more relatable!

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Can't I Just Write Notes on My iPhone?

qaprep.com

Knowing how to write psychotherapy progress notes in an efficient, HIPPA-compliant manner is a must.

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Counseling Wise

How to write psychotherapy notes: Great article that offers an exploration of writing psychotherapy notes in a creative way such that you can gain more insights into how to better work with clients.

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The Poetics of Progress Notes

psychotherapynetworker.org

Psychotherapy notes software: TherapyNotes is one of the more highly advertised electronic psychotherapy notes solutions available to therapists. Like many of these systems offered to private practice clinicians, this system is a cloud-based one, which means that you don't need to install it on your computer(s), but can simply access it via the internet. Check with other clinicians before you attempt to implement any of these EHR systems to ensure that you understand the pros and cons for…

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therapynotes.com

Psychotherapy notes software: PracticePro Therapy practice management software for Psychotherapists is one of many options available today for private practice psychologists, therapists, and counselors. I've not used it. For any of these programs, make sure that you talk to other therapists who have actually used the program, to ensure that it provides the functionality you want in your practice.

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PracticePro Therapy psychotherapy practice management software

practiceprotherapy.com

from GoodTherapy.org Therapy Blog

Protecting the Privacy of Foster Kids’ Therapy Notes

Insightful article about psychotherapy notes, privacy, and HIPAA as it relates to treating foster kids. The article does a good job of addressing the issues of psychotherapy notes being given unique privacy protections within the HIPAA Privacy Rule, more so than all other protected health information (PHI), including purely diagnostic or evaluative information, case notes, other treatment services, etc.

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Protecting the Privacy of Foster Kids’ Therapy Notes

goodtherapy.org

S.O.A.P. notes for psychotherapy sessions. This article gives an example of how to write SOAP notes. Keep in mind, as mentioned in other pins here on this board, if you are using electronic records or psychotherapy progress note software, you should clearly delineate between the SOAP note part of your notes and the psychotherapy notes part, so that sensitive data is HIPAA compliant and private.

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Clinical Case Notes

become-an-effective-psychotherapist.com

This is a great article that walks us through the risks of including psychotherapy notes, as opposed to S.O.A.P. notes in the electronic health record for your client.

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psychcentral.com