Some guidelines for keeping psychotherapy progress notes

Note Designer note-taking software was developed to be consistent with best practices in the field. Here are some of the guidelines that were consulted during this development.

The following are quoted from the document “Record Keeping Guidelines”, from the American Psychological Association:

  • Psychologists have a professional and ethical responsibility to develop and maintain records (Ethics Code 6.01).
  • A psychologist endeavors to include only information germane to the purposes for the service provided (Ethics Code 4.04). Additionally, consistent with the Ethics Code (Principle A), psychologists are sensitive to the potential impact of the language used in the record (e.g., derogatory terms, pathologizing language) on the client.
  • For each substantive contact with a client [a note should include]:
    • date of service and duration of session;
    • types of services (e.g., consultation, assessment, treatment, training); nature of professional intervention or contact (e.g., treatment modalities, referral, letters, e-mail, phone contacts);
    • formal or informal assessment of client status;
  • The record may also include other specific information, depending upon circumstances:
    • client responses or reactions to professional interventions;
    • current risk factors in relation to dangerousness to self or others;
    • other treatment modalities employed such as medication or biofeedback treatment;
    • emergency interventions (e.g., specially scheduled sessions, hospitalizations);
    • plans for future interventions;
    • information describing the qualitative aspects of the professional/client interaction;
    • prognosis;
    • assessment or summary data (e.g., psychological testing, structured interviews, behavioral ratings, client behavior logs);
    • consultations with or referrals to other professionals;
    • case-related telephone, mail, and e-mail contacts;
    • relevant cultural and sociopolitical factors.

For software to help with preparing your therapy notes, visit NoteDesigner.com

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