My Therapist Keeps Taking Notes. What Are They Writing About Me?

Similar to how there are different therapy modalities, there are a number of ways therapists take notes. This can feel a bit awkward if you’re pouring your heart out and then see them jotting down notes. They aren’t judging you—but it can definitely feel like that. You don’t know whether they are writing down what you just said, an observation about your body language, or their thoughts on the situation. 

That said, one way to feel more comfortable about going to therapy is to understand more about the process. To help you better understand therapy notes, we spoke to therapists about what they are actually writing down and why it’s important for them and you. 

Why does my therapist write things down? 

Therapists write notes for a variety of reasons. Mainly, it’s to remember what you said in session and to keep track of your progress. 

“The truth is that the therapist is making notes for themselves during the session about the client and their life to assist them in remembering information and also for sparking topics of interest,” says Leah Sauls, a licensed therapist at UpLift.

Similar to how your doctor takes your vitals at an annual checkup, your therapist is taking down vital points about your mental and emotional health.

What notes is my therapist taking?

There are different topic areas that a therapist may include in your progress note (which is different from a psychotherapy note). Here are some of the most common ones:

Symptoms and observations

Whether you’ve started therapy for the treatment of anxiety, depression, obsessive-compulsive disorder, or something else, you’ll likely present with a set of symptoms. Your therapist is probably already familiar with the symptoms. They take notes to record what you were experiencing when you started your sessions, so you can track your progress together.

For example, you might tell your therapist you’re tearful more days than not or have difficulty sleeping. They’ll write this down and keep track of it throughout your following sessions to see how you’re progressing. 

In the same vein, in order to make a diagnosis, a number of symptoms have to be present for specific periods of time. Documenting your progress is the only way a therapist can easily keep track of the symptoms you’re experiencing, how severe they are, and how long you feel them. This can be important for understanding if something is working and how to change course if it’s not.

Personal information 

Have you ever wondered how your therapist remembers your best friend’s name? A birthday? The name of your dog? They probably have it written down in their notes. It could leave a bad taste in your mouth if you were talking about your best friend and every session your therapist asked who that was two months in—were they even listening in the first place? 

They may also be writing down key events, pivotal moments, and life-changing experiences you’ve shared with them. Let’s say you lost a parent or loved one or your dog is battling cancer. These events are important for your therapist to know as it could exacerbate your symptoms or make you feel more sad or anxious than usual. 

Wins and milestones 

You might have outlined some goals for your treatment when you first started therapy. Not only did your therapist take note of those at the beginning of treatment, but they are also keeping track of your improvement. 

Let’s say you were nervous about giving a speech because of social anxiety, but at your next session you told your therapist you delivered the speech. This can be a huge milestone if it wasn’t something you had done before or that you hadn’t done in a while. Your therapist may use this as evidence that your current treatment plan is working and that you’re closer towards achieving your goals.

Potential treatment options  

Another area where your therapist may take notes is if they have potential treatment options. As you’re talking, your therapist might think of a tool or coping strategy that they think could be beneficial for you. Instead of interrupting you in the middle of a thought, they may simply write it down and refer to it later, whether that’s a breathing technique, mindfulness exercise, or a helpful DBT skill. 

Session recap

After your session, your therapist will write what is known as “progress notes,” also known as “clinical notes.” This is typically a few sentences about what the client reported in session and the information presented by the therapist. They might report patterns or observations they’ve noticed about your body language, eye contact, and other subtle signs that can be indicative of overall mental health.

What is the difference between progress notes and psychotherapy notes?

Therapists take more than one kind of note. These notes serve different purposes and have different legal and clinical rules surrounding them. 

Let’s start with the similarities: Both types of notes cover many of the areas we’ve already laid out, like your wins, symptoms, context about your life, and other things. Both notes help a therapist keep track of your progress so that your treatment can go better. 

Psychotherapy notes are personal (but professional) notes that therapists use to remember and process your sessions. It’s just for their own benefit as your provider. Sometimes, it’s called “chicken scratch.” These notes aren’t considered part of a medical record and could be difficult for someone else—even the client—to understand. 

Imagine psychotherapy like scribbling down a single word on a napkin to remind yourself of something later or tying a string around your finger. It holds little meaning to anyone but the person who wrote it. Psychotherapy notes likely hold more detail and value but they are considered personal notes and confidential. 

These types of notes don’t necessarily include information about your prescriptions, how long a session lasted, or results of clinical tests.

Progress notes, on the other hand, do have this type of information and more. It includes information about your diagnosis, your prognosis, your treatment, which types of therapy are used as part of your treatment and how often.

These are considered clinical notes and are part of your health record. Though these are also confidential, there are instances where you or another provider who is treating you may be able to access them. 

Can I ask for my therapist notes?

Therapy notes are confidential—but yes, you can ask your therapist to see your notes. (On UpLift, you can request your progress notes by signing a release of information.) Some therapists may want to have a discussion with you about why you want to see your notes, but you do have a right to see your clinical notes. It’s likely you may not understand what your therapist has written down since it could be in clinical language, but you can ask them to explain further.

Aside from you, therapy notes are confidential. They aren’t allowed to share the contents of your notes with anyone else without your permission. In some cases, they may want to share notes with other doctors to fill them in on your situation but you would still need to consent. 

“While the privacy rule does grant access to client's medical records, HIPAA does deny access to therapist's [psychotherapy] notes,” says Sauls. “This is due to the psychotherapy notes being primarily intended for the use of the mental health clinician.”

Though the HIPAA Privacy Rule is a federal one that means you can’t always access your therapist’s psychotherapy notes, state laws sometimes come first. Depending on where you live, you may have greater access to it. 

Therapy notes are a vital part of the process for both the therapist and the client. That said, some people feel uncomfortable with a therapist taking notes in session. In some cases, a therapist will hold off until afterwards and then jot down the main points. You’ll want to discuss this with your provider if the prospect of them taking notes in sessions provokes anxiety. 

Ready to find a provider who gets you and can help you achieve your goals? UpLift has tools to match you with a therapist or psychiatric provider that works for you—because everyone deserves access to a provider that understands them.