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Psychotherapy Notes

Date of Publication

3/26/2012

Definition

Notes recorded, in any medium, by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private, group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

Source of Definition

DoD Instruction 6490.10: Continuity of Behavioral Health Care for Transferring and Transitioning Service Members

Related Glossary Terms

Psychotherapy Notes | Psychotherapy Notes

Last Updated: January 16, 2020

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