Therapists typically take notes during sessions to aid them in recalling important information and to keep track of the client’s progress. These notes can involve information about the client’s symptoms, goals and history. Note keeping can help the therapist to reflect on previous sessions and plan future sessions or interventions, as well as help maintain objectivity.
Therapists are trained to take notes in a respectful manner that adheres to confidentiality, privacy and accuracy. Notes may also be used as a legal record to protect the client and therapist in the event of a legal dispute.
Notes are kept in a secure space and are only shared with other professionals if it is necessary to the client’s care. Patients are allowed to request copies of their notes.