The Best Way to Secure Your Therapy Progress Notes

Are you looking for a more efficient and secure way to take therapy progress notes in your mental healthcare practice? The way that therapy progress notes and psychotherapy notes are taken and secured is vital to effective long-term client care — and for your own protection as a clinician running a successful private practice.

Whether writing SOAP notes or DAP notes, too many mental health professionals use therapy notes methods that are inefficient at best and not HIPAA compliant at worst. In most cases, these inefficient note writing ways are due to unintentional negligence. For example, a mental health professional with their own private practice might take therapy notes in whatever ways are most convenient for their busy schedule: scrawling into a notebook, typing into a free Google Doc, or even dictating therapy progress notes into a phone.

But none of those options guarantees the security of your clinical impressions, client treatment plans, or other private information in any given mental health progress note. Plus, with each of those methods, you're stuck with putting in the extra effort to summarize the notes for billing purposes later on.

Instead of any of these methods, mental health care clinicians should keep their therapy notes in an encrypted system with multiple backups for the mandatory several years required by law.

In this article, learn more about the common pitfalls of ineffective progress note documentation methods, and the reasons why using an electronic health records (EHR) platform like Orchid is the best way to take and secure your therapy notes, psychotherapy notes, and client treatment plans.

What Are the Consequences of Not Securing Progress Notes?

If you don't establish a HIPAA compliant process for keeping encrypted therapy progress notes, it puts you at risk of facing penalties ranging from $100 to $50,000 per individual violation.

Even years after treatment goals have been completed, a mental health care clinician can be subpoenaed to provide a client's medical history, so it's crucial to the success of your career to adopt the safest, most effective way to keep progress notes. After all, without those therapy progress notes to review, being compelled to testify at a deposition can be a challenging experience.

Common Pitfall #1: Taking Progress Notes by Hand

One common note taking method is to use an old-school paper notebook.

Why aren't handwritten progress notes secure?

• They can be easily destroyed in any number of ways (fire, flood, or proverbial the dog could eat your homework). And with no back-up copy of say, your SOAP notes? That's all, folks. All that subjective and objective data is gone, all that meticulously documented information like a chief complaint or the thoughtfully constructed therapeutic interventions in your treatment plan are no more. 
• Your notebook could get lost anywhere. For example, if you lose it on public transportation, that puts your clients at risk of exposure. 
• You could accidentally leave the therapy notes sitting out as you leave the room, and an ill-intentioned person could rifle through them and glean confidential information. 
• Handwritten notes aren't searchable in the way EHR software's progress note templates like a SOAP note are. That means, when it's time to process billing and invoicing, a handwritten note-taker must slog through the manual process of locating and duplicating the appropriate information. With an EHR, that process is streamlined with electronic client charts, which leaves little room for human error, while saving the clinician from plenty of headaches and wasted time. 

Common Pitfall #2: Saving Progress Notes on your Personal Device

It's also common to take mental health progress notes through audio recording methods or writing them in documents on a computer, phone, or tablet. These methods might seem more secure if done on a password-protected device, but there are still several issues with them.

Progress Notes on a Computer

Even if your computer is protected by a password and always stays locked up in your home or office, there's a danger to saving progress notes directly on your computer alone.

Example of a risky computer therapy notes scenario:

Let's say a distraught therapist's computer has recently fried. Because of that hard drive failure, for the next few weeks, the therapist scours their memory for details about every single client they've had. They spend valuable time and energy trying to recreate the treatment plan histories for each therapy session. But if this therapist had gone to a computer repair shop, they would have faced another major issue with this note-keeping method: if the data is even retrievable, there's always the risk that a repairperson would read their private progress notes, which could challenge legally-mandated confidentiality.

Progress Notes on a Phone or Tablet

Taking notes on your mobile devices include all the combined risks of keeping therapy notes on paper or in your computer.

Why aren't therapy progress notes secure on your phone or tablet?

• Taking notes on a mobile device isn't safe because it's just as easy to lose a phone or tablet as it is to leave that notebook on the bus.
• Every time you upgrade to a new device, you risk forgetting to transfer the notes.
• Despite the protection that cases provide, it's easy to drop mobile devices and break them, which would instantly lose any therapy notes you hadn't saved to the cloud yet.
• Saving notes to the cloud violates HIPAA compliance just like saving them in a document saved to your computer would be.
• If you get subpoenaed, the court will have access to your entire phone, including personal things you might not want them to see.

It's safer for you — and for your clients — to keep progress notes separate from your personal devices and in a dedicated space, such as an EHR platform like Orchid.

Progress Notes on Audio Tapes

Recording audio on any of your devices poses the same risks as keeping written notes on those devices. Analog audio tape recordings are also risky, since they can become demagnetized and easily lose those records. Plus, if you use any kind of transcription service, that introduces another step that can put a hole in your security and breach client confidentiality.

Common Pitfall #3: Typing Notes in Google Docs

On the surface, keeping progress notes in the free version of Google Docs may seem like a better option than the previous methods. After all, cloud-based note-keeping makes your therapy progress notes less vulnerable to a computer meltdown. However, cloud-based software introduces other crucial issues. 

Why isn't Google Docs secure for therapy notes?

Most importantly, the free version of Google Docs and similar cloud-based word processors are not HIPAA compliant. Because Google Docs is designed for documents to be shared, it's too easy to accidentally share therapy progress notes with someone who isn't authorized to see them.

For example, you could inadvertently alter your document's access settings and create an open link rather than a restricted one. That would leave confidential information vulnerable not only to people who aren't your clients, but also expose the information to search bots. 

The paid version of Google Docs is far more secure, but why pay for Google Docs when there are systems that integrate everything you need for your practice, like a HIPAA compliant EHR platform?

Your Best Bet: Keeping Progress Notes in Orchid

No other mental health progress note taking method is as secure and efficient as taking progress notes in your practice's own customizable EHR software account.

Orchid is an affordable EHR developed by mental health professionals for mental health professionals. With Orchid's HIPAA compliant platform, you can take and maintain secure progress notes in a system that also makes it easy to manage your practice as a whole. 

The benefits of taking progress notes in Orchid are clear: 

• Orchid provides you with a therapy progress note template that's fully customizable. That makes it easy for you to fill in your notes on treatment plans for each therapy session and even add attachments as needed.
• The therapy progress note template in Orchid also includes the option to add psychotherapy notes.
• Generating receipts and superbills for each therapy session becomes a cinch. Those templates pull in client information you've already recorded in the progress note templates, which saves you from the stress of repetitive manual work.
• If you're ever audited by an insurance company, Orchid makes sure your confidential records are in order (i.e., a client medical record that is fully HIPAA compliant).
• Since Orchid is designed to communicate cleanly with other systems, it's safe and simple to transfer therapy notes in or out as required. 

All of those integrated features save you valuable time — hundreds of hours a year, in fact. Knowing that your progress notes can be taken efficiently and stored securely means you can focus on what really matters: helping your clients.

Try Orchid today (and get your first month on us).