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Therapist vs. clinician: Which term should you use in documentation?

Documentation is complicated. It can be confusing to know which term providers should use. Read our guide to see what’s right for you.

Dr. Anum Ali
Dr. Anum Ali, LPCTherapist

Documentation in healthcare can be complex, and choosing the right terminology is often one of the most confusing aspects. Should you refer to yourself as a “therapist” or a “clinician” in your notes? While these terms may seem interchangeable at first glance, there are important distinctions between them that could impact compliance, billing, and clarity in your records. 

Using the wrong term can also have consequences for insurance claims, patient care coordination, and even legal compliance. This guide will help you understand the differences between the two terms and provide guidance on when (and why) you should use each in your documentation. By the end, you’ll be better equipped to navigate this confusion and make the right choice for your practice.

Defining clinician and therapist

The terms "clinician" and "therapist" are often used interchangeably in everyday conversation, but in the context of healthcare documentation, there are important distinctions to note. Choosing the wrong term in documentation could lead to confusion, billing issues, or compliance concerns.

Clinician

A clinician is a broad term that refers to any healthcare provider who delivers patient care or services. This term encompasses a wide range of healthcare roles, including:

  • Psychiatrists
  • Nurse practitioners
  • Clinical psychologists
  • Social workers (providing services beyond therapy)
  • Occupational or physical therapists


Clinicians may hold various licenses or qualifications, and the term does not specify the type of care or therapy provided.

Therapist

The term "therapist" in behavioral health is more specific and generally refers to a professional who provides psychotherapeutic interventions, including:

  • Licensed professional counselors (LPC)
  • Marriage and family therapists (LMFT)
  • Licensed clinical social workers (LCSW)
  • Mental health counselors (LMHC)


In documentation, "therapist" is used to indicate a professional providing focused therapeutic interventions.

Which term should you use?

The term you choose will depend on your specific professional role and the context in which you are writing. Let’s look at when each term is appropriate.

Provider type 1: Clinician

Use "clinician" if your role involves broad healthcare services, particularly in clinical or multidisciplinary settings. Examples include:

  • Psychiatrists: While they provide therapy, their primary role is medication management.
  • Nurse practitioners: Offers a combination of therapeutic and medical services.
  • Social workers: If you're providing a broad range of clinical services (beyond therapy), "clinician" is more accurate.


"Clinician" is appropriate in a multidisciplinary setting where your specific role might not be clear or needs to be more general.

Provider type 2: Therapist

Use "therapist" when your primary role is to deliver psychotherapeutic care, particularly in mental health, behavioral health, or rehabilitation settings. Examples include:

  • LPCs: Specifically trained to provide psychotherapy
  • LMFTs: Specialized in relationship and family therapy
  • LCSWs: Specifically provides counseling services
  • Mental health counselors: Focused on therapy for mental health challenges


The term "therapist" should be used when your practice involves direct therapeutic services.

For more details on best practices for documentation, visit our compliance and documentation resource collection.

Headway makes documentation easy.

At Headway, we understand how challenging documentation and compliance can be. That’s why we’ve streamlined the process to help you focus on what matters most: providing high-quality care. Our platform offers customizable templates, integrated tools, and compliance checks to ensure your documentation meets both industry standards and regulatory requirements. Let Headway support you in maintaining an efficient and compliant practice—so you can spend less time on paperwork and more time with your clients.

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