Do you love to work with patients but detest writing psychotherapy reports? If you feel that taking notes is a tedious and never-ending task, or if you find it not clinically relevant.

I understand! 

Writing is a challenge; you resent the lengthy process, worry about legal issues, and lose sleep worrying about audits and income.

You are not alone; many health practitioners hate entering the data to create the reports manually. Doctors love helping patients but dread doing paperwork in private practice. The good news is that most psychiatrists depend on the best and most sophisticated psychonline software for creating health records.

I can understand why you’re confused. Graduate school doesn’t teach you how to write psychotherapy reports because every health care system after graduation uses a unique system depending on the population’s needs.

However, there’s no avoiding creating these medical records.

But, what are “Psychotherapy reports”?

Psychotherapy reports are records prepared by psychologists and psychiatrists summarizing counseling sessions and kept with individuals’ medical records. They may exclude medical prescriptions, medical modalities, and treatment frequencies in most cases.

They also document patient and therapy insights. The report includes the therapist’s hypothesis, observations, and feelings about the session. Notably, these reports are kept private from the client while care providers require patient permission to access them. 

How to Write Psychotherapy Reports

There is a unique format to be followed when writing these reports since they are optional. A psychologist can create brainstorming diagrams and may include the following:

• Your thoughts or hypotheses

• Observations you made about the client

• An opinion or feeling you have about a client or a therapy session

• Queries to ask your supervisor

• Your research interests

Even though psychotherapy reports are not legal documents, there are still a few rules to follow. These psychotherapy reports are considered to be private and not medical records.

However, the following information must be excluded from psychotherapy reports to be determined as a personal record and not part of the medical documents:

• Medications

• Diagnosis and symptoms

• Treatment plan

• Medication monitoring

• session start and stop times

• Clinical test results

• Functional status

• Progress

• Treatment methods and frequencies

Tips to Consider When Writing Psychotherapy Reports

Notably, the personal note may contain opinions, ideas, feelings, and other information that does not belong in medical records. Nonetheless, it would help if you considered the following:

Maintain Confidentiality: you must keep psychotherapy reports confidential despite being your private notes. Ensure you don’t leave your notebook open for others to read. Also, ensure you protect psychotherapy reports with a password when using a computer.

Moreover, when including your thoughts and opinions about the clients, be careful not to put them on the client’s progress notes. Therefore, you shouldn’t have incriminating information that you wouldn’t want criminal justice to see.

They should be kept apart: Psychotherapy records should not be merged with those of medical care. The psychotherapy reports are considered part of their medical records if they cannot be distinguished from their progress notes or general chart.

To keep confidentiality, you can use an electronic health record system that complies with HIPAA regulations to create psychotherapy reports. We invite you to try PsychOnline EHR free of charge or contact us via info@psychonline.com.