Key terms on this page (6)
- Progress note
- The record of one session or contact: what happened, your assessment and the plan. Required for every billed service.
- Treatment plan
- The written agreement on what you are treating, the goals, how you will measure them and what you will do. Notes refer back to it.
- Medical necessity
- A payer’s test for whether a service is needed to diagnose or treat a condition. Defined by each payer, and shown in your documentation.
- Psychotherapy notes
- Under HIPAA, private notes analyzing a session, kept separate from the record. A narrow category with extra protection.
- Designated record set
- HIPAA’s term for the records a provider uses to make decisions about a client. Clients have a right to access it.
- Mental status exam (MSE)
- A structured description of how the client presents: appearance, behavior, speech, mood and affect, thought, cognition, insight.
What a note is for
Your first notes will feel like homework. They aren’t. A good note lets you pick up where you left off next week, lets a colleague cover for you safely if you are ill, shows a licensing board or a court what you did and why, and shows an insurer that the session was needed. Those readers want the same thing: what happened, what it means, what is next.
Every profession’s code requires you to keep records. The ACA, AAMFT, NASW and APA all ask that records be accurate, timely, kept securely and sufficient to support the services you provided. Your state adds rules on what to keep and for how long, and your employer adds a template.
One session, three formats
The three formats you will meet most often are SOAP, DAP and BIRP. Below is the same invented session written in each. Switch between the tabs and watch the facts stay put while the headings move.
Often used in: Medical settings, hospitals and integrated care, where the rest of the team writes SOAP too.
Sample progress note · invented client
Individual session, 50 minutes, in person · Adult client · Diagnosis on file: F41.1 generalized anxiety disorder · Treatment plan goal 1, objective 1b
- SubjectiveWhat the client tells you
Client reported worrying “most days” about work performance and an upcoming review. Rated average anxiety this week 7/10 (8/10 last week). Sleeping 5–6 hours; trouble falling asleep 3 of 7 nights. Completed the worry log on 4 of 7 days.
Denied suicidal thoughts, intent or plan when asked directly.
- ObjectiveWhat you observe and measure
On time, alert and oriented. Speech normal in rate and volume. Affect anxious and congruent with content; fidgeting early in the session eased by the midpoint. GAD-7 today 13 (moderate range), down from 15 two weeks ago.
Reviewed worry log. Used cognitive restructuring with a thought record on two predictions about the review (“I’ll be fired”, “everyone will see I’m a fraud”). Gave brief psychoeducation on stimulus control for sleep.
- AssessmentWhat it means clinically
Client engaged well, generated two balanced alternatives and rated belief in “I’ll be fired” as dropping from 80% to 40%. Said the sleep steps felt “doable”.
Anxiety improved modestly, from the severe into the moderate range (GAD-7 15 → 13, self-rating 8 → 7). Sleep and concentration at work remain impaired, which supports continued weekly treatment. Risk: low, no change from the last assessment.
- PlanWhat happens next
Continue weekly individual CBT per treatment plan. Homework: daily worry log, one behavioral experiment (send a draft report after one read-through), stimulus-control steps nightly. Readminister GAD-7 in two weeks. Next session in one week.
Signed and dated by the clinician (and co-signed by the supervisor, if you are pre-licensed).
A few habits that make any format work:
- Quote sparingly, measure often. A short quote in the client’s words is vivid; a score from a validated measure shows change over time.
- Describe, don’t label. “Raised voice, left the room twice” tells a reader more than “hostile”, and is fairer to the client.
- Always record risk when you assess it, including when the answer is no, and what you did about it. The risk and crisis step covers what to ask.
- Write it the same day. Many employers and payers set a deadline. Late notes are less accurate and look worse if anyone ever asks.
- Never alter a signed note. If you need to fix something, add a dated, signed addendum. Changing an old note after a complaint can turn a defensible case into an indefensible one.
The treatment plan behind the note
The treatment plan is the document every note leans on. It names what you are treating, what the client wants to be different, and how you will both know it is working. Write it with the client in the first few sessions and revisit it regularly; many agencies and payers set a review schedule.
Sample treatment plan · invented client
- Diagnosis
- F41.1 generalized anxiety disorder
- Problem, in the client’s words
- “I can’t switch off. I lie awake going over work, and I’m making mistakes because I’m so tired.”
- Goal 1
- Worry takes up less of the day, so the client can sleep and focus at work.
- Objective 1a
- GAD-7 below 10 on two readings in a row, within 16 weeks (baseline 15).
- Objective 1b
- Uses a thought record to challenge a worry at least 4 days a week, within 8 weeks, by self-report and log.
- Objective 1c
- Falls asleep within 30 minutes on 5 of 7 nights, within 12 weeks (baseline 3 of 7), by sleep log.
- Interventions
- Cognitive behavioral therapy: psychoeducation, worry log, cognitive restructuring, behavioral experiments, stimulus control for sleep.
- Frequency
- Weekly 50-minute individual sessions.
- Review
- Every 90 days, or sooner if symptoms change. Client participated in writing this plan and agrees with it.
The test of a good objective is whether someone else could tell, in a few months, whether it was met. “Feel less anxious” can’t be checked; “GAD-7 below 10 on two readings in a row” can.
Medical necessity, in plain terms
When an insurer pays for therapy, it pays for services that are needed to treat a diagnosed condition. Medicare’s version comes from federal law, which excludes services that are not “reasonable and necessary” for diagnosis or treatment. Private insurers write their own definitions, but they look for the same chain in your record:
- A diagnosis, supported by what you assessed.
- Symptoms that impair the client’s functioning: sleep, work, school, relationships, self-care.
- A plan with goals aimed at that impairment, and a reason to expect therapy to help.
- Notes that show you delivered that treatment, and how the client is responding.
- A reason to continue: still impaired, still improving, or at risk of getting worse without care.
When one of those links is missing, payers can deny claims or ask for money back after an audit. When a client has met their goals, the honest move is to say so, update the plan or plan the ending. That is good care, not a billing problem.
Your notes and your psychotherapy notes
HIPAA gives one kind of mental health documentation extra protection: psychotherapy notes. The category is narrower than the name suggests. It covers notes that document or analyze what was said in a session, kept separate from the rest of the record. Everything else, including your progress notes, is part of the client’s record.
Try sorting these six.
Where does each one belong? Nothing is saved or sent.
1. The session started at 2:04 and ended at 2:54.
2. Your own reflections on a dream the client described, and what it stirred in you, kept in a separate locked file.
3. The client’s GAD-7 score today was 13.
4. A summary of the treatment plan and progress toward the first goal.
5. Detailed process notes about the session, typed into the progress-note field of the clinic’s record.
6. Your hypotheses about the client’s reaction to you, jotted in a private notebook to take to supervision.
The difference matters. Clients have a right to see and copy their record, and you can deny that only on narrow grounds. Psychotherapy notes are not part of that right, and you generally need the client’s specific written authorization to disclose them, even to another treating clinician. A health plan cannot make that authorization a condition of paying for treatment.
Many clinicians keep no psychotherapy notes at all and simply write careful progress notes. If you do keep them, store them apart from the chart, and never put anything in them that a colleague would need to treat the client safely.
Notes as legal records
Your record can be requested by a licensing board investigating a complaint, subpoenaed in a custody dispute or lawsuit, or audited by an insurer. In each case it is read by someone who wasn’t in the room. A subpoena alone is not always enough to release records, so check with your supervisor, your employer’s privacy officer or your liability insurer before you send anything. The confidentiality step covers this in more depth.
How long you keep records is set by your state and your profession’s code, and is often longer for minors. Look up your board’s rule on the requirements pages or your board’s own site, and follow your employer’s policy if it is stricter.
Myths worth dropping
Myth
“Longer notes protect you better.”
Actually
Clear, relevant notes protect you. Pages of process detail add risk and are harder for anyone to use.
Myth
“Clients can’t see their therapy notes.”
Actually
They can usually see the whole record, including progress notes. Only separately kept psychotherapy notes are excluded.
Myth
“If a client is doing well, write less.”
Actually
Progress is exactly what a reviewer looks for. A short note that shows it, and a plan to taper or end, is good documentation.
Next · Step 16
Telehealth and state lines
Video sessions make it easy to forget that licenses stop at state lines. Next: why the client’s location decides which rules apply, and what the interstate compacts do and don’t solve.
Questions people ask
What is the difference between SOAP, DAP and BIRP notes?
They are three ways of arranging the same facts. SOAP splits the session into subjective, objective, assessment and plan; DAP folds the first two into a single data section; BIRP is organized around behavior, your intervention and the client’s response, then the plan. None is required by law. Use the format your site or electronic record uses.
Can clients read their therapy notes?
Usually, yes. Under HIPAA, clients have a right to see and get a copy of their record, which includes progress notes, treatment plans and test results. The exception is psychotherapy notes: private notes kept separately from the record, which clients have no automatic right to see. Some states add their own rules, and a clinician can deny access only on narrow grounds.
What are psychotherapy notes under HIPAA?
Notes a mental health professional writes to document or analyze what was said in a session, kept separate from the rest of the record. They never include session times, the type and frequency of treatment, test results, or summaries of diagnosis, symptoms, functional status, the treatment plan, prognosis or progress. Disclosing them generally requires the client’s specific written authorization.
How long does a progress note need to be?
Long enough to show what happened, why it was needed and what comes next, and usually no longer. A clear note for a routine session is often a short paragraph per section. Risk assessments, crises and unusual decisions deserve more detail.
How long do therapists have to keep records?
It depends on your state and profession, and is often longer for minors. Check your state board’s rules and your professional code, and follow your employer’s policy if it is stricter.
Sources
Checked 28 October 2026. The sample note and plan are invented for teaching. Payer rules and state retention periods vary; follow your site’s policies and your supervisor.
- HHS, HIPAA Privacy Rule: definitions (45 CFR 164.501) — The definition of psychotherapy notes, including what they never contain.
- HHS, HIPAA Privacy Rule: authorizations (45 CFR 164.508) — Authorization required to disclose psychotherapy notes; plans may not condition treatment or payment on it.
- HHS, HIPAA Privacy Rule: access of individuals (45 CFR 164.524) — The client’s right to see and copy the designated record set, and its exclusion of psychotherapy notes.
- HHS, HIPAA and mental health — Guidance on psychotherapy notes and sharing mental health information.
- Social Security Act §1862(a)(1)(A) — Medicare excludes items and services that are not reasonable and necessary for diagnosis or treatment.
- ACA Code of Ethics (2014), Section A.1.b — Counselors’ duty to keep records and documentation.
- AAMFT Code of Ethics (2015) — Standards on maintaining and protecting client records.
- NASW Code of Ethics, Standard 3.04 — Client records: accurate, timely, sufficient, and stored securely.
- APA, Record Keeping Guidelines (2007) — Content, security and retention of psychologists’ records.