Therapy progress notes: a treasure trove of data for all the wrong people

Did you know your client’s progress notes are almost certainly the place you are most likely to harm them?

You might think of progress notes as an aid to therapy: somewhere to keep track of your thoughts, or to jot down ideas and hypotheses. Other people see them very differently. To them, your notes are a honeypot of data that can be used against your client.

Who reads your notes

In the wrong hands, a progress note can do significant damage.

Insurance companies can use them to deny a claim or to downplay the seriousness of a payout. When a client applies for life insurance, or when they die and the insurer is looking for a reason not to pay, a line about an old pre-existing condition can be enough.
Courts, especially in family law, can use them to argue that someone is or isn’t a fit parent. When couples separate, a partner’s lawyer can subpoena your file.
Criminal matters can put notes to uses they were never intended for.
Your client may one day ask to read their own file.

And when a subpoena arrives, it covers everything in your possession: scratch notes, audio and video recordings, transcripts. If it exists, you hand it over. Those things belong nowhere near a client’s file, and should be deleted as soon as practicable.

The myth of the complete note

Somewhere in the history of psychology we decided that notes should be so comprehensive that another psychologist could pick them up and carry on therapy seamlessly, based on the notes alone.

Picture the handover. “Your father was an abusive alcoholic.” “What? My father? I never said that.” “Well, it’s in the notes.” All that, from forty minutes that felt like a week and a half.

We can’t record everything that happened in a session in enough detail for someone else to take over. Good notes are not a transcript. They are a carefully balanced set of factual statements, descriptions and memory prompts, designed to give you enough to carry on therapy. Many things that were said are deliberately left out.

So we need to ask what our notes are actually for. To me, their main job is managing risk.

The risks notes should manage

Our memory. It is fallible. We will forget a client’s name, parts of their history or their demographic details. Notes cover those lapses.
What happened in therapy. We can’t try a technique in session five, forget, and try it again in session ten.
The risks of your setting. Every organisation and every context has its own specific risks to manage. That is why there can’t be one standard note template across all of psychology. Each setting is mitigating different things.

Every addition has a cost

Once you’ve dealt with memory and treatment history, ask what other risks your notes need to manage, and what you need to add to cover them.

But here’s the catch. Every time you add something new to your note template, you create a risk that it will harm the client, or harm you.

So before you add anything, ask yourself two questions. Why am I adding this? And what risk does this addition create?

Then read a finished note and ask: would I be comfortable if this were read by the client? By an insurance assessor? By their former partner’s lawyer? By a claims adjuster after they’ve died? If the answer to any of those is no, the note is doing more than it needs to.

A template is a starting point

None of this means starting from a blank page. A good template saves time and keeps you consistent. Just treat it as a starting point, not a standard: adapt it to the risks of your setting, and strip out anything that doesn’t earn its place.

If you want somewhere to start, the note-taking template we used at Benchmark is available through PREP.

AI note-takers add a whole new layer to this risk. I’ve written about that in AI client notes for psychologists.