The Differences Between Psychotherapy Notes and Progress Notes

Unlike psychotherapy notes, progress notes are meant to be shared with other healthcare workers who assist with a patient's treatment plan. Progress notes inform staff about patient care and communicate treatment plans, medical history, and other vital information. Without accurate and up-to-date progress notes, healthcare professionals would need to start from the beginning each time they met with a patient. They would waste time and increase the risk of making a medical mistake.

It's best for progress notes to follow a template, so all staff members document in the same way. Progress notes should be easy to access, clearly written, and consistent in style to help minimize mistakes or misunderstandings. Progress notes are also essential documents in regard to billing and reimbursement.

Healthcare providers are required to keep accurate progress notes to legally protect their patients and provide care for patients they see on a daily basis. Each progress note must address the following four components — subjective, objective, assessment, and plan (SOAP).

• Subjective: Describes the patient's current condition as explained by the patient. The "chief complaint" is required. For example, if a patient complains of chest pain and a cough, this would be the chief complaint. A history of the patient's symptoms is also recorded here in the patient's own words.
• Objective: Includes findings from a physical examination.
• Assessment: Includes a summary of the patient's diagnosis.
• Plan: Includes what the healthcare provider will do to treat the patient. The plan portion of a progress note also includes follow-up information, referrals, lab orders, and a review of all the medications a patient is taking.

Although progress notes are read by trained staff on a regular basis, they are still protected under the HIPAA Privacy Rule.
In general, the following information is protected under HIPAA:

• Any individually identifiable health information relating to the individual's past, present, or future physical or mental health
• The type of healthcare provided to the individual and the reasons for the care
• Information regarding the past, present or future payment for the care and treatment given to the individual

Individual identifiers include information such as name, address, birth date, or social security number.

As with most rules, there are a few exceptions.
A healthcare provider may disclose or use a patient's medical information or progress notes when:

• The Privacy Rule permits
• The patient authorizes the use or disclosure in writing

In some cases, a healthcare provider is required to disclose patient information. This occurs when:

• The individual request their information
• The HHS is conducting an investigation and requesting the information
• Law enforcement requests the information

Sometimes a healthcare provider is permitted to disclose patient information to protect a patient or the public from harm.
The following circumstances do not require a patient's authorization for disclosure:

• For treatment, payment, or healthcare operations
• For public interest and benefits as required by law to prevent or control a disease
• For government authorities in cases of abuse, neglect, or domestic violence
• For health oversight agencies during audits or investigations
• For judicial or administrative proceedings
• For law enforcement purposes
• For funeral directors, medical examiners, or coroners as needed
• For research purposes
• When there are threats to public health or safety
• For essential government functions
• In regards to workers' compensation law

When an individual is incapacitated, in an emergency situation, or not available, a healthcare professional may use their best judgment in deciding to disclose patient information to family members or personal representatives. In such a case, they could use informal authorization from the patient if possible.

Under HIPAA law, a healthcare provider must train all employees, volunteers, and trainees to comply with privacy policies and procedures, and they must discipline those who violate HIPAA regulations. It is every healthcare provider's responsibility to make sure all data, like progress notes, is secure at all times, whether they need to shred paper documents or make sure electronic passcodes are set.

Because HIPAA requires highly secure record-keeping, it's best for healthcare practices to take proper precautions and store records electronically. When progress notes are stored electronically, they can be protected with passwords and virus protection. However, paper documents can be easily damaged, lost, misread, or accessed by the wrong people and offer little protection for the patient.