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The Most Important Things to Include in a Counseling Note

The Most Important Things to Include in a Counseling Note

When providing mental health treatment for a patient, a mental health professional will keep several pieces of documentation. One of the most important of these is the counseling note. But what is it exactly, and how is it different from other types of notes?

What Is a Counseling Note?

A counseling note is also referred to as a psychotherapy note, a process note or a private note. It contains the hypotheses, observations, thoughts and further questions the treating mental health professional may have about the patient during a counseling session. A counseling note serves as a reference point for the mental health provider regarding the patient’s diagnosis and progress.

Counseling notes are always separate from billing information and medical records and may never be shared without prior authorization from the patient. Also, they may not be shared with patients or other staff, since they are the counselor’s private notes. Last, but certainly not least, because they contain highly sensitive information, the Patient Privacy Rule affords them special protection.

However, there may be instances where the counselor is required to disclose their counseling notes, for example for treatment, in certain legal situations, to avert a serious threat to public safety, during an investigation of the Department of Health and Human Services or when a medical examiner needs the information for their duties.

Counseling Note Template

Because mental health providers aren’t required to keep counseling notes, there’s no set format for this type of documentation. However, the following template lists the most important things to include in a counseling note:

  • Names: List the names of the counselor and patient, as well as the health care institution where the counseling is taking place.
  • Type of Session: Is it an individual, marital or family session?
  • Date: Listing the date of the session makes it easier to build up a timeline of the patient’s progress.
  • Start Time: Knowing the start time of the session allows the mental health professional to monitor the amount of time they’re spending on each patient.
  • The Progress of the Patient Since the Last Session: It’s essential to gain an impression of the patient’s current state before beginning the session. For example, have they managed their symptoms, or has anything noteworthy occurred?
  • Observations About the Patient: Here, the mental health professional lists anything they notice about the patient, for example, that they look tired or disheveled — or, in contrast, rested, well-groomed and confident.
  • Review of Any Action Items: If the patient was expected to practice any skills or perform any actions, this is discussed.
  • Session Preparation: This part may be filled out in advance of the session since it can contain any significant items from the previous meeting and the goals for this session.
  • A Brief Description of the Session: This serves as a general outline of what is discussed.
  • The Main Issue of the Session: Here, the mental health professional describes the main problem the patient is struggling with.
  • Substance Abuse: This can be a simple “yes” or “no” answer.
  • Danger: If the patient is experiencing suicidal or homicidal ideation, list it here.
  • Homework: If action items are assigned for the patient to complete, note them here.
  • Need for Additional Insights: If the counselor needs to follow up with their supervisor, make a note of it.
  • Next Appointment: The date the patient will come in for the next session is agreed upon.
  • End Time: List the time that the session ended.
  • Signature: The counselor’s signature verifies all the information in the counseling note is accurate.

Create Secure Counseling Notes With ICANotes

For psychiatrists, psychologists, licensed social workers and other mental health providers, it’s critical to be able to create secure counseling notes that they can refer to as needed during a patient’s treatment. ICANotes provides a comprehensive platform that delivers the ease-of-use you need while still providing patients with the protection they’re entitled to by law.

To learn more, register for our webinar on Wednesday, June 5, 2019, at 12 p.m., or contact us for more information.

 

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