Have you tried to get your therapy notes?

I glanced at my T’s notes on me yesterday. He has a little chart in his file with the date of the session and then there are three blank bullet points. Not enough room for a complete sentence, just enough to jot an idea. Last session was the only session on this sheet and he only used the first bullet point and it was 4-5 words. His handwriting is a bit tough to read and I am not concerned about what he is writing so I didn’t stare.

I tried to get the notes of my first T more than a year after terminating and he just deflected and pretty much refused but failed to tell me directly. I stopped pursuing it as it just made me frustrated unnecessarily. I do suspect that he is not on top of note keeping though as being incompetent with even simple administrative things such as preparing properly done invoices for insurance submission and keeping track of appointment cancellations were recurring issues with him in the past.

I do think that for some disorganized people that refusing or delaying providing requested notes may be because they are in poor shape or missing or both. When I requested to see mine, my T opened the computer file and let me look at them for as long as they wanted. They were current, concise, and decidedly not interesting to me. But he is always on time, always reliable, so I'm not surprised his notes were consistent with his other professional skills (which should be the norm for Ts as well as all professions, but sadly are not). Over the years, my work has been made more difficult by the disorganization of files as kept by other attorneys. I've received some client files that look like a kid who's just shoved papers into the bottom of his backpack for years, then thrown them into a box and mailed them to me.

Just wondering, is a T supposed to takes notes after each and every session? What is the expectation / requirement?

I don't think there is a requirement with perhaps the exception of clients who file with insurance. I would hope if your therapist is under contract with insurance providers and/or you are filing with insurance, that there is some paperwork involved since diagnostic codes, billing codes, etc. must be verifiable.

screenshot — imgbb.com
Old Therapist's response to my text.... we shall see.

That's great Sarah.

Thanks for the follow up! I was about to ask if anyone had tried asking.

My pdoc is not budging. He would rather I didn’t sue him for the notes and said people have tried and failed.

Anyone know a good hacker?

That would really make me want to know what was in them that I couldn't see...

I assume you are joking about hacking the system.

I’m like half joking. This is killing me inside but I can’t just sue him over this!

This is funny because I think like 3 sessions ago, my T was talking about how I’ve made progress even though it’s difficult for me to see it, and he randomly goes “maybe someday you and I can look over every note I’ve taken of you and you can see how far you’ve come.” I’d never mentioned wanting to see my notes. I don’t have a strong desire to see them but I also wouldn’t mind. I am kinda curious but tbh they are probably pretty boring in reality.

I assume he's an ex-T, but what about asking if you can come in and look at the notes, booking a session if that is what he's willing to do? The issue is sometimes more about you having a copy of the notes and the implications of that (i.e. ruminating on them, etc) for your supposed mental health as opposed to you looking at them.

I looked at my notes for about 10 minutes once in a session, it was a spontaneous thing and T just put me in front of his computer. In retrospect I know that they are not revealing at all of my identity (a para for each session) and that is comforting to know, they have no detail of my life. They were upsetting because I realized all the times I'd avoiding something, that it wasn't my T's forgetfulness, I wasn't pulling anything over on him by failing to mention something I was trying to bring into session and work on. If the question is whether the notes revealed "what he really thought about me", then they were thoroughly useless.

Therapist response. Still thinking about how I feel about it.

I personally don't like the policy that a T can decide subjectively what notes to show the client upon request. I see it a bit similarly to doctors not sharing with a patient their full diagnosis and perspectives. It gives room for covering up sloppiness and if the notes are usually very short and stick to the facts, I don't quite see why to hide them in the client's interest when they decide that they want to see.

Ex-t but still my pdoc.

He offered to pull up notes from a particular date and discuss it.

[Ugh. Just leave me alone and give me my notes so I don’t forget my seven year experience (which you are sullying btw doc, FYI)]

Thank you for starting this thread! Legal health records are an extremely important thing to consider when in therapy and or seeking help from any healthcare professional. They are LEGAL record and can and will be used against you in a court of law.

I have indeed got my records. They were altered and falsified in preparation for a potential lawsuit after I experienced medical malpractice and threatened a lawsuit. Lies were written in my charts that would creatively defend the criminals and destroy my credibility beyond repair. Fortunately, this issue is being exposed slowly but surely. Ultimately what needs to happen - is that legal health records should NO LONGER be considered legal records. They should merely be someone else's notes, no different than if you or I were to write sessions notes after a session. Aside from all the potential issues regarding memory of events and misconstrued information, there is also FAR too much power afforded to healthcare professionals because they know how these documents can be utilized in a court of law or complaint processes. Not to mention they can be altered and falsified in preparation for subpoenas and complaints - it is absolutely baffling that policy and legislation has not yet changed.

Look up, "Alteration of medical records," on google. Enjoy the rabbit hole. Inform yourself. And DO order your records. Just because your therapist seems trustworthy and ethical does not mean they are - there is absolutely nothing stopping them from being unethical aside from their promise to uphold their ethics. Unfortunately I was fooled by that.

Thanks,
HD7970ghz

Thanks for sharing this Sarahsweets,

I would still recommend getting copies of everything regardless of what your therapist says. Knowing what I know can be done to health records - I see what your therapist said as a major red flag...

Thanks,
HD7970ghz

In Canada they are all required to keep notes of all sessions and even phone or email interactions. They could be subpoena'd by a court at any time, or required by health care. Practitioners here can lose their license for note keeping proper notes.

It varies province to province, as well as depending on an individual’s qualifications. It also depends if you are in the public system or if you are paying someone privately. I see someone currently who is licensed as a social worker and while she keeps notes they are very brief. She probably does note phone calls/emails but if they are anything like her session notes they don’t say much. We talked about it once because I don’t trust people and didn’t really like the idea of a big file full of personal details hanging out there. She read me some and showed me that while they are there, and she could bring them to court or something if needed, she also likes to use a system that keeps things more confidential.