session notes

[BSWdavid]

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Anyone have a suggestion for taking good session notes that can be used in supervision, treatment planning, etc? I am not referring to progress notes, which are kept in the chart, but process notes which belong to the therapist.

For example: specific formats, where to keep notes (file cabinet in therapist's office or in a notebook), etc.

 

[stigmata]

The best thing you can do is to not keep them at all. They are discoverable by law and almost always can only hurt you.

 

[deleted176373]

The best thing you can do is to not keep them at all. They are discoverable by law and almost always can only hurt you.

+1, it seems overwhelming at first to keep all this information on all your clients in your head, but you get better at it pretty quickly.

Mark

 

[O Gurl]

I have a related question if anyone can offer advice:


A former clinical practicum supervisor recently contacted me requesting that I return my process notes under the principle that they are property of the university and were made while seeing clients under her supervision. I had a very similar understanding as you guys in that I thought the process notes were the property of the therapist. Is this different when working under the supervision of someone else?

 

[stigmata]

In this case it is probably the case that the process notes, and ANY other documentation you may have should remain at the practicum site. These rules and distinctions apply directly to licensed providers in relation to legal and ethical guidelines, but while you are in training the actual provider is your supervisor and the facility.

 

[O Gurl]

I see. Thanks for the insight. I'm still kinda confused as to why she wants them back since I have been done at that site since April and she has the actual progress notes, but I guess I shall just send my chicken-scratch notes back to avoid any issues... just don't know why I feel so weird doing so. ???

 

[BSWdavid]

+1, it seems overwhelming at first to keep all this information on all your clients in your head, but you get better at it pretty quickly.

Mark

How can the notes hurt you?

 

[stigmata]

O-girl, ya it is certainly weird!!

BSWDavid, please tell me you are pulling my chain..

 

[BSWdavid]

O-girl, ya it is certainly weird!!

BSWDavid, please tell me you are pulling my chain..

Well, I have just started working with patients. I was under the impression that HIPPA law states that psychotherapy notes are the property of the therapist and don't have to be released to anyone, therefore, how can they hurt you if no one else has access to them?

 

[deleted176373]

Well, I have just started working with patients. I was under the impression that HIPPA law states that psychotherapy notes are the property of the therapist and don't have to be released to anyone, therefore, how can they hurt you if no one else has access to them?

Trust me on this... These are subject to subpoena, and if it can be shown that you were somehow negligent (regardless of whether you actually were negligent) you can be in a world of hurt. It's a lot easier to say, I don't recall and sorry, I don't have process notes for that encounter.

Mark

 

[BSWdavid]

Trust me on this... There are subject to subpoena, and if it can be shown that you were somehow negligent (regardless of whether you actually were negligent) you can be in a world of hurt. It's a lot easier to say, I don't recall and sorry, I don't have process notes for that encounter.

Mark

Gotcha, thanks for the info. It really kinda sucks, especially while I am learning, as it would be helpful to write my thoughts down, organize them, etc. It is a shame that it has come down to this.

 

[erg923]

Where in HIPPA is there a provision for "process notes" being protected? Our program taught us NOT to do this, due to forensic issues everyone has brought up.

 

[Therapist4Chnge]

Process notes may be helpful for some, but they open up a world of possible liability. I kept them for writing my notes and supervision purposes, but then I shredded them.

 

[jdawgg]

Where in HIPPA is there a provision for "process notes" being protected? Our program taught us NOT to do this, due to forensic issues everyone has brought up.

Under HIPAA, separately filed "psychotherapy notes" are specifically protected from release to patients, though state law supercedes this. They are not protected from release through a court order, however. Given the difficulty in keeping such records separate and the lack of protection from release in court proceedings, you're right that it doesn't sound like a good idea to keep such notes.

 

[erg923]

Yea, "protected" from subpoena or court order is what I was referring to in that post...

 

[Ollie123]

While I agree with others that keeping extensive, detailed documentation around is not a good idea I'm not sure that means you should never write anything down besides the process notes.

It can help to jot down notes, plot out a structure and organize your thoughts when treatment planning. I'm not sure I see harm in keeping more extensive details around for a few days while you meet with your supervisor. For example, notes that you actually take during the session. I still do this sometimes and did it more frequently early on, but they were typically shred within no more than a week. Not a single supervisor, nor anyone else has even so much as hinted that doing so is a bad thing and they tend to be relatively conservative about those issues here.

 

[Shatani]

Process notes may be helpful for some, but they open up a world of possible liability. I kept them for writing my notes and supervision purposes, but then I shredded them.

this is what ive done as well...i have a really good memory, so all i really need are a few trigger words and im good. so, my process notes would be wholly unhelpful to anyone but me anyway. i just use them to prepare my DAP notes and remind me of things for supervision...