Are Therapists Obligated To Maintain Session Records?

Is it necessary to take notes during therapy sessions? This question often arises in the context of psychotherapy, and it’s a practice I frequently employ in my role as a clinical social worker, particularly when working with adolescents and families. The act of taking notes serves several valuable purposes. First, it aids in our preparation for future therapy sessions, allowing us to maintain a comprehensive record of the client’s progress and challenges. Moreover, notes serve as a helpful reference point, enabling us to revisit critical statements and discussions that warrant further exploration in subsequent sessions. This dual function of note-taking can be a valuable tool in the therapeutic process, enhancing the effectiveness of therapy sessions and fostering a more profound understanding of the client’s needs and progress.

Is it possible to request your therapist’s notes? Clinical notes are an essential part of your medical record, and you have a legal right to access them. However, it’s important to note that therapists often maintain two sets of notes: clinical notes, which document the essential aspects of your therapy sessions and are accessible to you upon request, and personal notes, which contain the therapist’s private reflections, questions, and thoughts. These personal notes are not guaranteed to be shared with you, but you can certainly inquire about them if you wish to understand more about your therapist’s perspective. As of February 28, 2022, this remains the general guideline for accessing therapist notes.