Sharing Therapy Notes With Patients: What the Law Requires and How to Write Them

You might feel nervous about clients reading your behavioral health notes. Some may find sensitive clinical observations upsetting, while others benefit from greater transparency and collaboration. Under HIPAA and the 21st Century Cures Act information blocking regulations, clients generally have the right to access their progress notes and other information in their designated medical records. Behavioral health practices must understand which records are accessible, what exceptions apply, and how to provide access without creating unnecessary barriers.

This guide explains what the law requires you to share in 2026, where psychotherapy notes fit, when you can withhold information and how to write notes you're comfortable having clients read.

What Does the 21st Century Cures Act Require Therapists to Share?

The 21st Century Cures Act prohibits information blocking: a practice that is likely to interfere with a client's access to, exchange or use of their electronic health information (EHI), unless the practice is required by law or meets an exception. The federal rule that puts this into practice took effect on April 5, 2021, and is overseen by the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health IT (ASTP/ONC).

The rule applies to three types of "actors": health care providers, developers of certified health IT and health information networks or exchanges. The federal definition of health care provider is broad. It includes community mental health centers, psychiatric hospitals, clinical psychologists, clinical social workers, physicians and therapists, among others. If you're unsure whether the rule applies to your practice, review the ASTP/ONC actor definitions with your compliance advisor.

How the Rules Have Changed Since 2021

What Behavioral Health Records Count as Electronic Health Information (EHI)?

EHI is electronic protected health information that is (or would be) part of the designated record set: the medical and billing records you use to make decisions about a client. In a behavioral health practice, that typically includes:

• Intake and diagnostic assessments
• Diagnoses, including the codes submitted for insurance
• Treatment plans and progress toward goals
• Progress notes
• Medication prescriptions and monitoring
• Screening results and test scores
• Discharge summaries and billing records

Clients have long had the right to request their records under the HIPAA Privacy Rule. The Cures Act adds a stronger expectation: you can't unreasonably delay or interfere with electronic access. In practice, many EHRs now release finalized notes to the patient portal automatically. (For handling formal records requests, see How to Give Patients Access to Their Mental Health Records.

Progress Notes vs. Psychotherapy Notes: Which Can Clients Access?

Under the HIPAA Privacy Rule, clients do not have a right to access their therapist's psychotherapy notes. HIPAA defines psychotherapy notes as a mental health professional's notes documenting or analyzing the contents of a counseling session, kept separate from the rest of the client's medical record.

Psychotherapy notes are also excluded from EHI, so the information blocking rule doesn't require you to share them. The exclusion depends on how you keep them, though. Notes that do not meet HIPAA's definition of separately maintained psychotherapy notes are not protected by that exclusion. Information documented in ordinary progress notes or used to make treatment decisions generally falls within the designated record set and may be subject to the client's right of access. HIPAA also gives you discretion to share psychotherapy notes with a client if you choose.

Several types of information never qualify as psychotherapy notes, even when a therapist records them: medication prescriptions and monitoring, session start and stop times, the modalities and frequency of treatment, clinical test results and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date.

For a deeper look at the definitions, see The Differences Between Psychotherapy Notes and Progress Notes.

When Can Therapists Withhold Notes Under Information Blocking Rules?

Not every request has to be fulfilled immediately or in full. ASTP/ONC has defined exceptions that protect you from an information blocking claim, as long as you meet every condition of the exception you rely on. These are the exceptions most relevant to behavioral health:

• Preventing harm: You may withhold information if you reasonably believe doing so will substantially reduce a risk of harm, and you withhold no more than necessary. When a client requests their own records, the risk generally must be to the life or physical safety of the client or another person. The determination must be made individually by a licensed clinician who has a relationship with the client, and the client can request a review.
• Privacy: You may hold back information when a state or federal law requires a precondition, such as a consent, that hasn't been met. You may also honor a client's own request not to share their information.
• Infeasibility: This covers situations where you can't fulfill a request, for example, because of a natural disaster or because you can't separate the requested data from information you're not allowed to share.
• Security and health IT performance: These cover reasonable practices that protect the security of EHI or temporarily take systems offline for maintenance.

Two practical points matter here. First, the preventing harm exception doesn't cover blanket policies, such as holding every note for a week, or concern that a client might feel upset. Emotional distress alone generally isn't enough when a client is accessing their own records. Second, document each decision to withhold, including the reason and the exception you relied on.

State laws, and federal rules such as 42 CFR Part 2 for some substance use disorder records, may add stricter requirements. Check how they apply to your practice.

What Does Research Say About Sharing Therapy Notes?

Many therapists are uncomfortable sharing notes with clients. As an article in the AMA Journal of Ethics notes, mental health professionals may be reluctant because of the ethical principle of nonmaleficence, or doing no harm. Reading behavioral health notes could cause anxiety or confusion, and some clients might be offended by what they read.

The research is more reassuring than many clinicians expect. OpenNotes, an international movement based at Beth Israel Deaconess Medical Center in Boston, began testing note-sharing in 2010. Social workers, psychologists and psychiatrists at Beth Israel Deaconess later opened their notes, too. Studies since then show:

• In a 2019 study of patients who read their psychotherapy notes online, 94% agreed that open therapy notes are a good idea, and 87% wanted the practice to continue.
• Among veterans receiving mental health care, 49% said reading their notes helped them feel in control of their care, and 45% said it increased their trust in their clinicians. A minority (8%) often felt upset after reading.
• Among patients with a serious mental illness diagnosis, 20% said reading their notes made them more likely to take their medication as prescribed, compared with 14% of patients with no mental health diagnosis.

The takeaway isn't that sharing is risk-free. Most clients find value in reading their notes, and the way you write them has a large effect on how clients react.

Benefits of Sharing Behavioral Health Notes With Patients

Some clients will never read their notes. Those who do often become more engaged with their care and more trusting of their clinicians. Sharing notes offers several advantages for clients and your practice:

Make Your Practice Ready for Open Notes

Take the guesswork out of sharing therapy notes with patients. Get five practical tools to help your team write client-ready documentation, protect patient privacy, and navigate compliance requirements.

• 50 Client-Ready Phrase Rewrites – Replace stigmatizing language with clear, respectful clinical documentation.
• Patient Handout & Intake Script – Explain note-sharing expectations and address privacy concerns.
• Withheld-Information Documentation Form – Record decisions to restrict access when applicable exceptions apply.
• Practice Self-Audit Checklist – Identify gaps in your documentation, patient access, and compliance workflows.

7 Tips for Writing Therapy Notes Clients Can Read

Clinicians are often most concerned about notes that cover sensitive topics, such as abuse or substance use. There are ways to document difficult topics with clarity and sensitivity. Write every note assuming the client will read it, even if they've never mentioned the portal. (For examples of complete notes, see our mental health record samples.)

1. Write Tactfully

Choose words carefully when covering sensitive topics so clients don't feel judged. Another way to use nonjudgmental language is to quote the client directly instead of summarizing. Rather than writing that a client drinks heavily, you might write, "Client states, 'I drink every day, but I can stop when I want to.'"

Avoid stigmatizing language. Focus on information relevant to assessment, treatment, safety, continuity of care, and medical necessity. Use neutral language, distinguish client reports from clinical observations or information provided by others, and avoid unnecessary sensitive details. Here's how a few common phrases change:

Writing respectfully does not mean minimizing clinical findings, omitting safety concerns, or weakening documentation needed to support diagnosis, treatment, and risk assessment.

2. Be Clear and Direct

Clients should be able to understand your notes. Avoid abbreviations, acronyms and jargon, and aim for clear, concise sentences. Plain language improves readability and can shorten documentation time. An article in The American Journal of Medicine offers these tips for writing helpful notes:

• Use bold font for instructions and other important details.
• Consider writing in the second person, using "you."
• Add links to educational resources that explain clinical terms.

If you need to include certain details for insurance, such as a diagnosis code, explain to clients what you documented and why. Transparency is key to a trusting relationship.

3. Get Clients Involved

Involve clients in the note-taking process and discuss what you'll write. Some clinicians turn their screen toward the client and write the note together at the end of the session. Make sure clients understand that you have professional requirements to meet.

You may also want to talk with clients about details they'd prefer to leave out. Let them know you value their privacy, but you also need to ensure continuity of care and document medical necessity. Work together to find the right balance. The goal is open communication and fewer surprises.

4. Ask for Feedback

Encourage clients to check your notes for accuracy and share their feedback. Let them know you're happy to talk through any concerns at their next visit, and remind them that you're working as a team toward their goals.

5. Include Accomplishments

Make sure your notes don't focus only on a client's problems. Include progress and accomplishments, too, so clients feel encouraged to stay on track. For example, instead of writing that a client still has panic attacks, you might write that their panic attacks have decreased from daily to twice a week and that they used a breathing technique to manage one at work.

6. Use an Efficient EHR System

Your EHR shapes how you write and share notes. Choose one that makes accurate note-taking simple, keeps psychotherapy notes separate from the record and offers a secure, easy-to-use patient portal. Features such as customizable templates and AI-assisted therapy notes can help you write clear, consistent documentation faster.

7. Set Expectations at Intake

Tell clients at intake that their notes are available through the portal and what they'll see, including diagnosis codes used for insurance. Explain that psychotherapy notes, if you keep them, are stored separately. Ask whether anyone else can get into their email or portal account. A few minutes of explanation upfront prevents surprises later and opens the door to the safety conversation described below.

How to Prepare Your Practice for Sharing Therapy Notes

How to Handle Challenges When Clients Read Their Therapy Notes

Note-sharing has many advantages, but it can also lead to challenging situations. Here are a few you might face and ways to handle them.

1. The Client Disagrees With You

Sometimes a client will disagree with your notes or your professional judgment. If that happens, record their perspective. For example, if a client believes a diagnosis is wrong, you might note that the client disagrees with the diagnosis and that you discussed their concerns. Let the client know you can't change your clinical judgment, and keep the conversation open.

Under HIPAA, clients can also formally request an amendment. You can deny a request if the record is accurate and complete, but you must explain the denial in writing. The client then has the right to submit a statement of disagreement that becomes part of their record.

2. There's Potential for Harm

In some cases, easy access to notes could put a client at risk. For example, a client may live with an abusive partner who could read their portal account.

Make sure clients understand how your practice releases records, and ask whether they have concerns. If a client fears a household member will see their notes, discuss options together. They may choose not to activate portal access, or they may ask you not to share certain information electronically. The information blocking rule allows you to honor a client's own request not to share. You can also review notes with the client privately during sessions. If you believe access could endanger the client's physical safety, the preventing harm exception may apply. Document your determination.

3. The Client Does Not Want to Include Traumatic Experiences

If a client isn't comfortable documenting the details of a traumatic experience, you have other options. Rather than describe the trauma, you might write that the client mentioned a significant past event and that you'll continue to explore it in future sessions.

How to Balance Risk and Respect When Sharing Behavioral Health Notes With Patients

Writing shareable notes means finding the right balance between risk and respect. You don't want to offend clients, but your notes still need to be accurate and truthful so clients get the right treatment.

Consider your client's wishes as you document. As the American Psychological Association points out, no laws require you to include every sensitive detail in the record. Use your judgment about which details are necessary. You might keep some information in your separate psychotherapy notes instead of your clinical documentation.

Don't hesitate to ask colleagues for guidance as you adjust to open notes. Learn ways to write empathetic, clear notes that keep clients engaged, and be prepared to coach clients on reading their notes and raising concerns with you.

Frequently Asked Questions

About the author

Dr. October Boyles

DNP, MSN, BSN, RN

Dr. October Boyles is a behavioral health expert and clinical leader with extensive expertise in nursing, compliance, and healthcare operations. With a Doctor of Nursing Practice (DNP) and advanced degrees in nursing, she specializes in evidence-based practices, EHR optimization, and improving outcomes in behavioral health settings. Dr. Boyles is passionate about empowering clinicians with the tools and strategies needed to deliver high-quality, patient-centered care.