How to Create a Psychotherapy Note

Mental health professionals have many details to remember about many different clients. Some therapists might see over 20 clients a week, yet they need to know each person as if they didn't have a full schedule. Writing psychotherapy notes allows counselors to grasp their clients' conditions to provide optimal care.

This guide will help you learn how to write psychotherapy notes using modern tools like ICANotes. We’ll explain the difference between psychotherapy and progress notes, what to include and exclude in a psychotherapy note, and how HIPAA rules apply to psychotherapy notes.

Table of Contents

• What’s New in 2025
• What Is a Psychotherapy Note?
• How Are Psychotherapy Notes Different From Progress Notes?
• How Do You Write a Psychotherapy Note?
• What Shouldn't Be Included in a Psychotherapy Note?
• Are Psychotherapy Notes Covered Under HIPAA?
• How Long Do I Keep Psychotherapy Notes?
• How Should I Dispose of Psychotherapy Notes?
• Essential Considerations for Writing Psychotherapy Notes
• Writing Psychotherapy Notes With ICANotes EHR

What’s New in 2025?

The way clinicians create psychotherapy notes and progress notes has evolved. In 2025, leading behavioral health platforms like ICANotes provide:

• AI-enhanced note-writing tools: ICANotes now offers an AI Scribe that generates editable drafts from live or recorded sessions.
• Built-in readability optimization: Notes can be cleaned, clarified, and standardized with a single click, improving privacy and accuracy.
• Group telehealth support: ICANotes telehealth now supports group sessions, virtual waiting rooms, and screen sharing — all launched directly from appointment calendars or patient charts — for seamless therapy continuity.
• Advanced privacy safeguards: All AI features in ICANotes are fully HIPAA-compliant and do not share data with external models. ICANotes encrypts patient data, offers audit logs, and ensures HIPAA and ONC-ATCB certification. No session data is used for external AI training—your records stay private.

What Is a Psychotherapy Note?

Psychotherapy notes are a counselor's private notes written during or after a counseling session. Unlike other forms of clinical documentation, psychotherapy notes are optional. They may be used to help a therapist analyze a session's content, form an impression, or explore their thoughts and feelings about a client and their condition.

These notes can:

• Help therapists reflect on client dynamics.
• Capture ideas for future sessions.
• Record therapist reactions and hypotheses.

They’re typically stored separately from the EHR’s main chart and are never shared with clients or third parties without consent (except under court order).

If you decide to write psychotherapy notes, you may find them helpful in gaining a clearer understanding of your clients and the treatment they need. You can record the notes in any medium you prefer, such as a notepad or laptop, as long as you keep the notes separate from clients' medical records.

How Are Psychotherapy Notes Different From Progress Notes?

Psychotherapy Notes	Progress Notes
Private, optional	Legal, required
Not shared	Shared with clients & providers
Subjective, exploratory	Objective, structured (e.g., SOAP format)
Exempt from info-sharing laws	Covered under the 21st Century Cures Act

Progress notes are clinical documents used to track diagnosis, symptoms, and treatment. Psychotherapy notes are excluded from the client’s chart as long as they remain separate and distinct.

Psychotherapy notes are not meant to be shared with others, unlike progress notes. Progress notes are legal documents that belong in a client's medical records and can be read by clients and other clinicians involved in a patient's treatment. Progress notes are also required for ethical and legal purposes.

Therapists keep progress notes to plan and document treatment and determine if therapy is helping a client improve. Counselors also keep progress notes to protect themselves legally, get reimbursed by insurance companies, and coordinate care with other healthcare providers.

Progress notes are brief and typically follow a standard format to communicate them easily to clients, clinicians, and insurance companies. For example, behavioral health professionals often use the subjective, objective, assessment, and plan (SOAP) format to write thorough and well-organized progress notes.

Unlike psychotherapy notes, progress notes must be easy to read so clinicians can quickly understand a client's medical history and current condition. Also, with the 21st Century Cures Act's information blocking rule, healthcare providers are required to give clients access to their medical records in the electronic health record (EHR) system, including their progress notes. Psychotherapy notes are exempt from the information-blocking rule as long as they are kept separate from clients' medical records.

How Do You Write a Psychotherapy Note?

Since psychotherapy notes are optional, there is no specific format you need to follow, nor do these notes need to be legible to others. For example, you can write notes in shorthand or create brainstorming diagrams if you wish. Regarding what you should write about, here's what you might include:

• Your observations about a client
• Your hypotheses or ideas
• Questions to ask your supervisor
• Topics you want to research
• Any thoughts or feelings you have about a therapy session and a client.

In 2025, many clinicians use ICANotes’ private psychotherapy note feature to compose these reflections in a secure, segregated space.

What Shouldn't Be Included in a Psychotherapy Note?

Even though psychotherapy notes are not legal documents like progress notes, there are still a few rules to consider. These rules establish your psychotherapy notes as your private notes and not medical records. According to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, psychotherapy notes must exclude the following information to be considered personal documents and not part of a client's medical record:

• Medications
• Medication monitoring
• Session start and stop times
• Clinical test results
• Treatment methods and frequencies
• Diagnosis
• Treatment plan
• Symptoms
• Functional status
• Prognosis
• Progress.

Are Psychotherapy Notes Covered Under HIPAA?

Yes, psychotherapy notes are covered under HIPAA, and there are protections for both therapists and clients. First, therapists are not required to share their private notes with clients, insurance companies, other healthcare providers, or anyone else. However, if a client requests to see a counselor's psychotherapy notes, the counselor can choose to share the notes if they wish.

Regarding clients' rights, counselors cannot share their psychotherapy notes without first obtaining the client's consent, with a few exceptions. Therapists may not need a client's authorization if they receive a court order.

How Long Do I Keep Psychotherapy Notes?

Because psychotherapy notes are optional, no rule states you must keep them for a specific amount of time. With that said, you may want to get rid of notes that are no longer helpful to you to eliminate the risk of someone else reading them. However, older psychotherapy notes may help you treat a particular client at a later time, depending on their needs. It's up to you to decide whether they are worth keeping.

The American Psychological Association (APA) provides general record-keeping guidelines you can apply to your psychotherapy notes if you prefer. According to the APA's guidelines, psychologists might retain an adult client's complete records for seven years after the last session or until three years after a minor reaches adulthood.

How Should I Dispose of Psychotherapy Notes?

If you decide to dispose of your psychotherapy notes, you'll want to implement the same safeguards you'd use for any client record to keep the information confidential. For instance, if you write psychotherapy notes on paper, consider shredding the notes when you no longer need them before throwing them away. Regardless of the disposal method you choose, it's essential that your notes are unreadable and cannot be reconstructed before placing them in the trash.

If you store your psychotherapy notes electronically, ensure your system is secure before deleting files. HIPAA provides examples of proper disposal methods for both paper records and electronic media.

Essential Considerations for Writing Psychotherapy Notes

In general, you're free to include your ideas, opinions, feelings, and other information that's not appropriate for medical records in your personal notes. But there are still a few things you'll want to keep in mind:

• Someone might read your psychotherapy notes: You can include thoughts and feelings you would not put into a client's progress notes. Still, you'll want to be careful with incriminating information because someone might read your notes under specific circumstances. Your private notes can be subpoenaed if there's a concern about public safety. So it's best not to include anything in your notes you wouldn't want a judge to see.
• You should keep them separate: It's a good practice to keep psychotherapy notes separate from a client's medical records. If your psychotherapy notes are not distinguishable from a client's progress notes or general chart, they will be considered part of their medical record. They can then be disclosed to other healthcare providers or insurance companies without the client's authorization.
• You still need to maintain confidentiality: Even though psychotherapy notes are your private notes, you still need to keep them confidential without a client's consent. If you write in a notebook, make sure you do not leave it out in the open for others to read. If you use a computer to write and store psychotherapy notes, ensure the notes are password-protected.

Frequently Asked Questions About Psychotherapy Notes

Q1: Can psychotherapy notes be stored in the same EHR as progress notes?

Yes, but they must be stored in a clearly separated, secure section of the EHR. Platforms like ICANotes are designed to enforce this separation and ensure psychotherapy notes remain confidential and exempt from the medical record.

Q2: Do insurance companies ever require access to psychotherapy notes?

No. Insurers typically only request access to progress notes for reimbursement. Psychotherapy notes are protected under HIPAA and cannot be shared with payers without explicit client consent.

Q3: What’s the best way to organize psychotherapy notes for multiple clients?

Use an EHR like ICANotes, which lets you tag, search, and organize notes by session, client, or therapist while keeping them separate from clinical charts.

Q4: Can clients request access to psychotherapy notes under the Cures Act?

No. The 21st Century Cures Act does not require providers to share psychotherapy notes as long as those notes are kept separate from the medical record.

Q5: Are psychotherapy notes required in every state?

No. They are optional everywhere. However, it’s good clinical practice for therapists who benefit from reflective documentation.