Clinical documentation is a cornerstone of ethical, effective therapy practice. Yet it can be confusing when to use progress notes versus process notes, and what distinguishes these two essential documentation types.

While both serve important functions in clinical work, progress notes and process notes have fundamentally different purposes, legal protections, and disclosure requirements. Understanding these differences isn't just about compliance—it's about protecting your clinical judgment, maintaining appropriate boundaries, and providing quality care.

This guide breaks down everything therapists need to know about progress notes and process notes, including what each type should contain, when to use them, and how they differ in terms of legal requirements and client access.

What Is a Process Note?

Process notes (sometimes called psychotherapy notes or personal notes) are private, informal reflections that therapists create for their own use. These notes capture the therapist's impressions, hypotheses, treatment considerations, and personal reactions that emerge during or after a session.

Unlike progress notes, process notes are not part of the official medical record. They're protected under special provisions of HIPAA and are considered the therapist's private working documents—tools for deepening clinical understanding rather than documenting service delivery.

Process notes might include observations about transference and countertransference, preliminary diagnostic impressions before confirmation, concerns about the therapeutic relationship, or the therapist's emotional reactions to session content. They serve as a space for honest clinical reflection without the constraints of formal documentation requirements.

What Process Notes Are Used For

Clinical Reflection

Process notes provide therapists with a confidential space to think through complex clinical material. They allow practitioners to explore hunches about underlying dynamics, consider alternative treatment approaches, and process their own emotional responses to challenging sessions. This reflective practice deepens clinical thinking and helps therapists recognize patterns that may not be immediately obvious during session.

Treatment Planning

While progress notes document what happened, process notes help therapists consider what should happen next. They're where clinicians work through questions like: Is this intervention effective? Should I adjust my approach? What might be contributing to this client's resistance? Process notes support more nuanced, thoughtful treatment planning by capturing the complexity of clinical decision-making.

Supervision and Consultation

Process notes are invaluable tools for supervision and peer consultation. They contain the rich clinical material—including the therapist's subjective experiences and preliminary hypotheses—that supervisors need to provide meaningful guidance. Many therapists bring process notes (or content from them) to supervision sessions to facilitate deeper exploration of clinical challenges.

What Is a Progress Note?

Progress notes are formal, objective documentation of therapeutic services provided. These notes are part of the client's official medical record and serve both clinical and administrative functions. They document that a session occurred, summarize what was addressed, describe interventions used, and track the client's progress toward treatment goals.

Progress notes must meet specific legal and regulatory requirements. They're subject to disclosure for insurance audits, legal proceedings, and—in most cases—client access requests. Because of these disclosure requirements, progress notes focus on observable, measurable information rather than the therapist's subjective impressions or clinical speculation.

Most importantly, progress notes are required for insurance reimbursement and must demonstrate medical necessity for continued treatment.

What Progress Notes Typically Include

Session Date and Duration

Every progress note must document when the session occurred and how long it lasted. This basic information establishes that services were rendered and supports billing accuracy. Many payers have specific requirements about how quickly notes must be completed after the session date—often within 24-72 hours.

Interventions Used

Progress notes should clearly identify the therapeutic techniques and interventions employed during the session. Rather than vague statements like "provided therapy," effective progress notes specify approaches such as cognitive restructuring, exposure exercises, motivational interviewing, or emotion regulation skills training. This specificity demonstrates clinical appropriateness and supports medical necessity.

Client Response

Documenting how the client responded to interventions is critical for demonstrating progress and justifying continued treatment. Notes should include observable indicators such as the client's engagement level, their ability to practice new skills, changes in affect or behavior during session, or their self-reported improvements between sessions.

Progress Toward Goals

Progress notes must explicitly connect session content to the client's treatment goals. This might include updates on symptom severity, functioning improvements, skill acquisition, or movement toward specific behavioral objectives. Clear documentation of progress (or lack thereof) justifies ongoing treatment and guides necessary adjustments to the treatment plan.

Legal Requirements for Progress Notes

Required for Insurance Reimbursement

Insurance companies require progress notes as proof that services were rendered and medically necessary. Without compliant documentation, claims can be denied even months after services were provided. Notes must demonstrate that treatment aligns with the client's diagnosis, addresses impairment in functioning, and follows an appropriate treatment plan.

Subject to Audits and Record Requests

Progress notes can be requested during insurance audits, which may occur randomly or in response to billing patterns. Auditors review documentation to ensure services were appropriate, properly coded, and adequately documented. Insufficient progress notes can result in payback demands, where the therapist must return payments for improperly documented services.

Must Meet Payer and State Standards

Documentation requirements vary by insurance company and state regulations. Some payers have specific formatting requirements or minimum elements that must be included. Many states have their own recordkeeping laws that therapists must follow regardless of insurance requirements. Therapists must familiarize themselves with the standards that apply to their practice setting and client populations.

HIPAA, Client Access, and Subpoenas

Differences in Disclosure Requirements

Under HIPAA, clients generally have the right to access their progress notes as part of their medical record. However, process notes (psychotherapy notes) receive special protection and are excluded from standard access requests. Clients cannot compel disclosure of process notes unless specific exceptions apply, such as when the notes are needed for legal proceedings where the client has put their mental health at issue.

What Clients Can and Cannot Request

Clients can request and typically must be provided with:

• Progress notes documenting services provided

• Treatment plans and goals

• Diagnoses and assessments

• Medication records

• Test results and clinical summaries

Clients generally cannot compel access to:

• Process notes (psychotherapy notes) kept separately from the medical record

• Information compiled in anticipation of litigation

• Notes that would endanger the client or another person

Therapists should understand that during legal proceedings, courts may order disclosure of both progress notes and process notes, though process notes receive greater protection. When in doubt, consult with a healthcare attorney before releasing any clinical records.

Process Note Examples

Effective process notes are personal, reflective, and focused on the therapist's clinical thinking. They should be kept separate from the official medical record and written with the understanding that they're primarily for the therapist's use. Here are examples that illustrate the informal, exploratory tone appropriate for process notes:

Example 1: Exploring Countertransference

"Noticed I felt protective when client described their partner's criticism—reminded me of my own past relationship. Need to monitor whether this is affecting my objectivity about the partner. Wondering if I'm subtly encouraging client toward separation rather than staying neutral. Should bring this to supervision."

Example 2: Preliminary Diagnostic Considerations

"Seeing more signs that might suggest borderline traits—intense fear of abandonment, idealization/devaluation of me. But could also be complex trauma response. Don't want to pathologize too quickly. Want to explore this more before considering if diagnosis should be revised. Review Linehan's criteria."

Example 3: Treatment Planning Questions

"CBT approach isn't landing—client keeps intellectualizing. Wondering if we need to shift toward more experiential work, maybe ACT or somatic approaches. Client seems disconnected from emotional experience. What's the avoidance about? Consider bringing in metaphors or mindfulness exercises next session."

What to Include in Process Notes:

• Personal reactions and emotional responses

• Preliminary hypotheses requiring further assessment

• Questions about treatment direction

• Transference and countertransference observations

• Self-critique and areas for professional growth

• Exploratory thinking about diagnosis or dynamics

What to Avoid in Process Notes:

• Information needed for billing or insurance

• Objective session documentation

• Content that duplicates progress notes

• Information that would be needed in case of emergency

The key is that process notes capture your evolving clinical understanding in a space protected from routine disclosure requirements.

Progress Note Examples

Progress notes should be structured, objective, and focused on observable information. Many therapists use standardized formats like SOAP (Subjective, Objective, Assessment, Plan) or DAP (Data, Assessment, Plan) to ensure consistency. Here's an example of a compliant progress note:

Example: SOAP Format Progress Note

Subjective: Client reported increased anxiety this week (7/10) related to upcoming work presentation. Described difficulty sleeping (waking at 3 AM with racing thoughts) and avoidance of preparation tasks. Stated, "I keep telling myself I'll fail and everyone will judge me."

Objective: Client appeared tense with pressured speech at session start. Demonstrated good engagement with cognitive restructuring exercise. Affect brightened when discussing coping strategies. Homework from last session partially completed (2 of 4 thought records).

Assessment: Client continues to experience symptoms consistent with Generalized Anxiety Disorder, moderate severity. Demonstrated understanding of connection between catastrophic thinking and anxiety escalation. Progress toward Goal 1 (reduce anxiety symptoms) is evident with increased awareness of cognitive distortions. Limited progress on Goal 2 (improve sleep hygiene) due to continued thought rumination.

Plan: Continue weekly CBT focused on cognitive restructuring and exposure to avoided tasks. Introduced progressive muscle relaxation for sleep hygiene. Assigned: complete one thought record daily, practice relaxation technique nightly, prepare presentation outline as behavioral activation. Will reassess sleep patterns and presentation anxiety next session.

Key Elements of Compliant Progress Notes:

• Session date, time, and duration clearly documented

• Specific clinical observations with behavioral examples

• Direct connection to diagnosis and treatment goals

• Interventions clearly named and described

• Measurable indicators of progress or challenges

• Clear plan with specific next steps

• Professional, objective language throughout

• Documentation completed within payer timeframe requirements

This format provides all information needed for insurance reimbursement, legal defensibility, and continuity of care while maintaining appropriate clinical boundaries.

Process vs. Progress Notes: Quick Comparison

Understanding when to use each type of note requires clarity about their fundamental differences. Here's a comprehensive comparison:

Process Notes and Progress Notes Similarities

Both Support Treatment

Process notes and progress notes both serve the ultimate goal of providing quality care. Process notes support treatment by deepening the therapist's clinical understanding, while progress notes support treatment by documenting services and tracking outcomes. Neither should be seen as "busywork"—both are valuable tools when used appropriately.

Written by the Therapist

Both types of documentation represent the therapist's professional perspective and clinical judgment. They're created by the treating clinician based on direct observation and interaction with the client. Neither should be delegated to non-clinical staff or AI tools without appropriate professional review.

Based on the Same Session

Process notes and progress notes may draw from the same clinical encounter, though they document different aspects of it. A single session might generate both a formal progress note capturing what was done and a process note exploring what it might mean.

Process Notes

Informal: Process notes use conversational language and don't require adherence to specific formats or templates. They can include abbreviations, shorthand, incomplete thoughts, and working hypotheses.

Reflective: The content focuses on the therapist's internal experience, clinical questions, and evolving understanding. They capture uncertainty, exploration, and the messy reality of clinical thinking.

Private: Process notes are kept separately from the medical record and are intended solely for the therapist's use (and possibly supervision). They receive special HIPAA protections.

Not Shared or Billed: Process notes are not provided to insurance companies, cannot be used to justify billing, and are not routinely disclosed to clients or other parties.

Progress Notes

Formal: Progress notes follow structured formats and professional documentation standards. They use objective, clinical language appropriate for an official medical record.

Objective: The content focuses on observable information, measurable outcomes, and factual session details rather than the therapist's subjective impressions.

Part of Medical Record: Progress notes are official healthcare documents subject to the same retention, security, and disclosure requirements as other medical records.

Required for Billing and Audits: Progress notes are necessary for insurance reimbursement and must be available for review by payers, regulatory bodies, and in legal proceedings.

When Should Therapists Use Each Type of Note?

The decision about which type of note to create depends on the purpose and intended use of the documentation.

Scenarios for Process Notes:

Use process notes when you need to:

• Explore your emotional reactions to a challenging client or session

• Work through questions about diagnosis before making formal determinations

• Document concerns about the therapeutic relationship that need supervision

• Capture preliminary treatment planning ideas you're still developing

• Process countertransference or parallel process observations

• Record supervision discussions about specific clinical dilemmas

• Think through ethical concerns or boundary issues

For example, if you find yourself feeling unusually frustrated with a client and want to explore whether this reaction is meaningful clinical information or a sign you need support, a process note is the appropriate place for this exploration.

Scenarios for Progress Notes:

Use progress notes to:

• Document every session for which you bill insurance or the client

• Record services provided in compliance with legal and regulatory requirements

• Track progress toward treatment goals for outcome monitoring

• Maintain continuity of care documentation

• Create a defensible record of clinical decision-making

• Support coordination with other providers

• Fulfill requirements for state licensing board audits

For example, every time you provide a therapy session—whether individual, family, or group—you must create a progress note documenting that service.

Using Both Ethically and Efficiently:

Many therapists benefit from using both types of notes, but this requires clear systems:

• Keep process notes in a completely separate location from progress notes (different file, different system)

• Never include process note content in progress notes or vice versa

• Create progress notes first to fulfill documentation requirements, then add process notes if needed for deeper reflection

• Label documents clearly so process notes are never accidentally released

• Consider whether you actually need process notes—not every session requires both types

The most important principle is intentionality: know why you're creating each type of note and what function it serves in your clinical practice.

Final Thoughts

Understanding the distinction between progress notes and process notes isn't just about compliance—it's about protecting your ability to think deeply about your clinical work while meeting professional obligations. Progress notes create the documented record required for legal, ethical, and financial aspects of practice. Process notes protect the reflective space clinicians need for insight and growth.

Many therapists, especially early in their careers, conflate these two types of documentation or try to make one serve both purposes. This typically results in either progress notes that are too subjective and personal (creating disclosure risks) or process notes that are too formal and constrained (limiting their usefulness for reflection).

The solution is clarity about purpose. When documentation is needed for billing, recordkeeping, or accountability, create thorough, objective progress notes. When you need space to think through clinical complexity, explore your reactions, or develop treatment ideas, use protected process notes. Both serve essential but distinct functions in quality care.

As you develop your documentation practices, prioritize systems that make this distinction clear and sustainable. Your future self—and potentially your licensing board or legal counsel—will thank you for establishing clear boundaries between these two critical types of clinical documentation.