Why do Therapists Take Notes?
Photo by Kate Hliznitsova
Some people ask why therapists take notes all the time. From their perspective, jotting down background information in the first few meetings makes sense. But after that, they feel the therapist should just pay attention to what the patient is saying and not lose focus by taking notes. A few patients even tell me that they have fired their therapists because they were annoyed by the note-taking. Oh, I wish they had at least given their therapists a chance to explain. If they had, they might have formed a different opinion.
Note-taking is a common practice. It is one way of ensuring that the therapist is capturing and retaining pertinent information about each patient. Even if the therapist does not take notes during a session, other forms of recording may still be utilized; for example, dictation or electronic medical records (EMR). Note-taking is not only encouraged but often required. Not doing so is rare.
As for what therapists include in their notes, it depends. For the purpose of documentation and care coordination, the notes typically include personal and psychiatric history, past treatment, mental status, and current stressors. Many therapists also include the patient’s “chief complaints.” These are subjective statements which illustrate why the patient is seeking help and what the treatment goals should be. In the initial meeting — often called intake — the therapist will try to gather as much information as possible regarding the aforementioned topics. However, as therapy continues, any significant updates can and should be added into the patient’s records.
Ideally, clinical notes should offer enough information for the reader to feel reasonably informed about the patient. For example, when a therapist refers a patient for medication management, the therapist’s clinical notes should enable the new provider to have a good grasp of the patient’s history and presentation long before the visit. This does not mean that the new provider will simply rely on the notes to diagnose or prescribe. Rather, the notes make it possible for the new provider to jump right in and ask the most relevant questions in a limited time frame. Such efficiency will ensure that time can be spent on broadening the scope of the conversation.
In terms of access, only clinicians working with the patient are allowed to read the records. Patients are entitled to access their own medical records as well. If the visit takes place at a medical facility, they can contact the medical records department and request a copy. If the therapist is in private practice, the patient can simply make the request directly. One thing to note — not all notes are shared. For instance, the notes taken during a session regarding the therapist’s own observations, impressions, hypotheses, or questions are considered private notes. These private notes are different from medical records, and the patient does not have a right to access them.
Some may wonder, “Can I ask my therapist to share these private notes with me regardless?” Yes, you may certainly ask. But remember you are not guaranteed a copy just by asking, as these notes reflect your therapist’s private observations to which you have no legal right. Most of the time, the therapist will encourage a dialogue to address any concerns you may have. In the end, whether or not the therapist chooses to share is a personal decision. But either way, a conversation about why the request is made in the first place is indispensable and it can often lead to invaluable insights.