Progress notes vs. psychotherapy notes under HIPAA

HIPAA defines psychotherapy notes as a clinician's notes documenting or analyzing the conversation in a session, kept separate from the rest of the client's record. They get extra protection. Progress notes are part of the clinical record.

What counts as a progress note

HIPAA's definition of psychotherapy notes expressly excludes the core facts of treatment, which belong in the record:

• Session start and stop times
• The modalities and frequency of treatment
• Results of clinical tests
• Summaries of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress

What counts as psychotherapy notes

Your private analysis of the session: impressions, hypotheses, details you want to remember that aren't needed for the record. To keep their protected status, they must be kept separate from the medical record.

Why it matters

• Disclosing psychotherapy notes generally requires the client's specific authorization, beyond what covers the rest of the record.
• Payers review progress notes, not psychotherapy notes, so everything needed to support treatment belongs in the progress note.

This is a general overview, not legal advice. Your licensing board and state law may add requirements.