Psychotherapy notes
Recently a psychotherapist on LinkedIn wrote that after working online most of her (short) career, she has once again started seeing patients in person. Apparently she’d been typing verbatim notes, i.e., a transcript, while conducting sessions over video. Now she’s struggling to handwrite the same thing in front of patients in her office. She asked her fellow therapists: “How do you manage writing notes in face-to-face sessions without breaking your fingers?”
Here is my answer, along with some other thoughts about psychotherapy notes.
Aside from initial visits, I’ve never in 35 years taken notes during a psychotherapy session. Instead, I handwrite a short note immediately afterwards. That way I can devote full attention to the patient in the moment. Writing the note just after the session is important. Psychotherapy sessions are like dreams: they’re not hard to recall immediately afterward, but they “evaporate” quickly. When I’ve been delayed in writing a note, I’ve been able to do it, but not as well.
Even a fast typist can’t transcribe a psychotherapy session in real time—not while being present in the session as a therapist. Audio or video recording is much better for that, although it’s rarely needed outside of research settings or certain styles of psychotherapy supervision.
There are also “scribe” apps, many now with AI, that not only record but also organize and summarize therapy transcripts. I’ve never used one, and see no need. As noted in my previous post, it’s important that such apps preserve patient privacy, e.g., are HIPAA-compliant and do not share therapy recordings or their derivatives to train AI. Such apps also spare the clinician the cognitive work of organizing his or her thoughts about the session. This is a mixed blessing at best: it saves time and effort at the cost of engaging less deeply with the material. Also, the AI may not “conceptualize” the material the same way the clinician would, which in theory may affect the way treatment progresses.
In my experience, taking brief notes (about 7-10 lines... five minutes) immediately after the session is enough. When I review them before the next appointment, they jog additional memories, especially if I was paying full attention in the first place. This is also what I advise my trainees, and it seems to work for them too. Excessive note-taking is unnecessary and often bespeaks anxiety in newer psychotherapists.
In an institutional setting, or in any agency or group practice really, there are important benefits to keeping two sets of notes: the chart (or file), and separate process notes (or psychotherapy notes). The former is the official treatment record. It legally documents the professional service, and is shared with other “covered entities” under HIPAA. Typical guidelines are to document the facts: the session date, time, and duration, the nature of the service rendered, clinically pertinent facts such as medical issues and medication changes, risks such as suicidal or homicidal ideation, a brief assessment statement, and the immediate plan (return in one week, refer to Alcoholics Anonymous, etc).
Process notes, in contrast, are working notes written by and for the psychotherapist. They are not part of the official treatment record, and are not released to other clinicians for coordination of care, nor by patient request (however, they are subject to discovery by court order). They are the clinician “thinking out loud” about the case. As the name suggests, these notes record the process of the session: the topics discussed and the transitions from topic to topic, pertinent behaviors—the patient arrived late, fell silent after an outburst, was more jovial than usual, seemed guarded, forgot their checkbook, was unusually engaged, asked for advice, etc etc.—and even speculations, reveries, and countertransference feelings of the therapist.
Separating chart notes and process notes excludes sensitive material from the official record, yet the clinician is free to privately note speculative and highly sensitive material in order to personally reflect on the case.
But I confess that I’ve never kept separate process notes. As a solo practitioner, I’m the sole viewer of my notes 99% of the time. So my notes are a combination: a few lines that encompass the “facts” as well as some of the process. I omit particularly sensitive material (detailed dream reports, sexual matters) that I might have included in separate process notes. I tend to remember these details anyway. And in the back of my mind, I remain aware that the patient may someday request a copy of these notes, which they have every right to do.
However, I worry a bit about that remaining 1%: when a patient requests their file, or wants it released to a third party. I offer to write a one-page summary instead, and sometimes that’s enough. When it’s not, and the patient receives a complete copy of their chart, I offer to go over it with them, even if they are no longer my patient.
I’ve also received subpoenas for records several times over the years, i.e., very rarely. Generally this happens when my current or former patient is involved in a lawsuit, either as plaintiff or defendant. I invite the patient to have their lawyer attempt to quash the subpoena, assuming it isn’t theirs. Barring that, I copy and release the file, always informing the patient first. This has happened two or three times in my career.
Process notes are particularly useful for formal psychotherapy supervision. A colleague of mine long ago published1 on the unique pros and cons of process notes, audio recordings, and videotape in supervision. While hearing and seeing the “play by play” of the session clarifies transient dynamics, there is never time to view or listen to a whole therapy hour in supervision. Audio and video recording, and by extension verbatim transcripts derived from them, are best for presenting short excerpts, say the first five or ten minutes of the hour. Only process notes convey the flow of the whole session, as well as the unspoken thoughts and feelings of the therapist. Process notes also assist trainees in creating written psychodynamic formulations. This is an essential part of training, and often valuable in practice as well.
While documentation is essential for clinical, legal, and training purposes, it should never take precedence over the actual clinical encounter. The stereotypical “therapist with a clipboard,” as shown in the stock photo included here, is less than optimal in my opinion. It’s far more important that the psychotherapist be present, attentive, and attuned in the moment, engaged with the patient, than to be preoccupied collecting data for the chart. Even splitting attention between the patient and the clipboard is an unneeded trade-off. It’s a pity if the record of a basically sound treatment proves incomplete or unhelpful; it’s a tragedy if a failed treatment ends up perfectly documented.
Goldberg, D. A. (1985). Process Notes, Audio, and Videotape: Modes of Presentation in Psychotherapy Training. The Clinical Supervisor, 3(3), 3–14. https://doi.org/10.1300/J001v03n03_02
The Couples' Counselor I see with my wife places her notebook beneath a pillow when she's not writing. Honestly, that makes them much more distracting. I understand taking notes, and I wouldn't try to read writing upside down across the room ordinarily, but the extra flourish of hiding them makes me, probably unnecessarily, worried about what she's writing.
I saw a therapist for a few months who wrote her notes during the session *while looking directly at me*. I understand what she was trying to do, but it made me really uncomfortable.
My current therapist writes notes during the session, but I don't feel it interferes with our conversation. I still feel he is very present and not at all preoccupied. And I would love to see those notes!