What do psychotherapy or process notes include?

Psychotherapy or process notes are a specific type of documentation created by a therapist that contains their personal impressions, thoughts, and observations about a patient's therapy session, which are often more subjective in nature. These notes provide insight into the therapist’s perspective on the client's mental state, ongoing therapeutic processes, and the dynamics of the therapist-patient relationship.

In contrast to other types of documentation, such as a patient’s medical record or official assessments, psychotherapy notes are typically kept separate to ensure confidentiality and privacy. This separation is essential because these notes often contain sensitive insights that reflect the therapist's reasoning and interpretations, which may not be shared with other healthcare providers.

This specificity of content underscores the unique role that process notes play in therapy, centered on the therapeutic relationship and individual nuances observed by the therapist during sessions. By focusing on these impressions, treatment strategies can be tailored effectively to meet the needs of the patient.