For our third installment of our new blog series, we’re addressing a question we frequently receive from associates studying for the CA MFT or LCSW law and ethics exam: What is the difference between psychotherapy records and psychotherapy notes? Let’s break it down.
Psychotherapy records are mental health records that therapists must maintain for every client. This medical record typically consists of intake forms, assessments, symptomatology, diagnoses, modalities, frequency of treatment, treatment plan, mental status exams, weekly progress reports, and other factual information about the client.
Psychotherapy notes, often referred to as process or private notes, are optional documentation that’s kept separate from the client’s psychotherapy records. These private notes exclude the information outlined above; instead, they focus on therapists' observations, hypotheses, and thoughts or questions for future sessions.
Psychotherapy notes do not have to be disclosed to insurers or clients who want to see the client's medical records. Similarly, they are not disclosed with a general records subpoena. In rare cases, a subpoena by the court can specifically request psychotherapy notes. If this happens, then therapists are legally required to supply both the notes and records.
To learn more about client records, subpoena protocol, and HIPAA requirements, check out our CA MFT and LCSW law and ethics exam prep programs that outline exactly what you need to know to successfully pass the BBS exam. If you need one-on-one assistance while studying, you’ll also have 24/7 access to licensed exam coaches who will support you every step of the way.
CE Courses:
Looking for CE credits? Our continuing education library features a range of courses that fulfill BBS requirements, including our brand new telehealth course, which fulfills the 3-hour law and ethics requirement, as well as the new telehealth course requirement. Here is a discount code that will allow you to save on the course: TELEHEALTH10