Psychotherapy notes are the provider's notes documenting or analyzing a counseling session, maintained separately from the medical record. They exclude medication prescription and monitoring, session times, diagnoses, treatment plans, and progress to date.
Disclosure generally requires specific authorization even where other records may be released.
Alternative Names:
Process Notes, Therapy Notes
Why it Matters?
The definition is narrower than practitioners assume, since diagnoses, treatment plans, medication records, and session summaries in the chart are not psychotherapy notes and remain accessible through ordinary channels. Only separately maintained process notes qualify. Establishing whether the provider actually maintained separate notes, rather than accepting a blanket objection, is the necessary step when mental health records are sought.
Frequently Confused with
Related terms
Frequently asked questions
What is excluded from psychotherapy notes?
How should a blanket objection be addressed?
