Mental health records: what to track and why it matters for your care

Guides 6 min read
Guides·Sara NassereddinHealth Technology Writer·July 17, 2026· 6 min read

Mental health records are just as important as physical ones — but far fewer patients keep them. Here's what to document, where to store it, and how having a record changes the care you get.

Mental health records are, in most respects, no different from physical health records — they document your symptoms, diagnoses, treatments and progress over time. Yet many people don't keep them, and far fewer bring them to appointments with new providers.

This guide makes the case for keeping mental health records and explains what to track, how to store it, and how it changes the care you get.

Why mental health records matter

Mental health care is often fragmented: you might see a GP, a psychiatrist and a therapist, none of whom share notes. Starting with a new provider — which happens frequently given waitlists, moving, and changing circumstances — typically means starting from scratch. A patient who arrives with a documented history of their diagnoses, what treatments were tried and what worked changes the entire dynamic of that first appointment.

Records also matter for insurance — some policies require documented diagnosis and treatment history to approve mental health benefits. And over time, a personal record lets you spot patterns: which seasons are harder, how life events affect you, and whether a treatment is working.

What to document

  • Current diagnoses — as formally given by a psychiatrist or GP, with the date of diagnosis
  • Medications — name, dose, prescriber, start date, why it was changed or stopped
  • Psychological treatments tried — CBT, EMDR, DBT, etc., with approximate duration and outcomes
  • Hospitalisations — dates, reason, discharge summary
  • Assessments — standardised questionnaires like PHQ-9, GAD-7, any neuropsychological testing
  • Side effects experienced from medications
  • Triggers, patterns and seasonal changes you have observed
  • Emergency contacts and crisis resources

What to bring to a new provider

At a first appointment with a new psychiatrist or therapist, a one-page summary is far more useful than a folder of notes. Include: your diagnoses, the medications you've tried with outcomes, any crisis history, and what you're hoping to work on. Most providers will find this refreshing rather than presumptuous.

"Knowing a patient's medication history before they walk in the door means the first appointment can be about them, not paperwork."

Dr. Lina Haddad, CMO, Looms

Privacy and who can see mental health records

In most jurisdictions, mental health records carry enhanced privacy protections compared to general medical records. In Looms, you control exactly what any provider or person can see via time-limited share links — you choose which records to include and which to keep private. For a broader look at your rights over your own health information, our patient rights guide covers what the law entitles you to.

Practical tools

  • Keep a mood diary — even a simple daily rating helps you and your provider spot patterns
  • Use the symptom checker in Looms to log acute episodes with timestamps
  • Photograph any paper letters from psychiatrists or therapists and upload to your records
  • Add notes to records with context that isn't in the document — e.g. 'stopped this medication because of insomnia'