What information is considered the bare minimum in a medical psychotherapy note?

The bare minimum information included in a medical psychotherapy note typically encompasses diagnoses, treatment plans, and session times. This foundational data provides essential context for the therapeutic process and ensures continuity of care. Diagnoses help in understanding the client's mental health status and inform the direction of treatment. The treatment plan outlines the goals and strategies that will be employed to address the client's issues, while session times keep a record of when services were provided. This information is crucial for documenting care, facilitating communication among healthcare providers, and adhering to legal and ethical standards in clinical practice.

While detailed history, therapist reflections, and prior treatment reviews are important for comprehensive therapeutic documentation, they exceed the minimum requirements needed to justify the provision of services and ensure clarity in treatment.