Not all behavioral health records are created equal. Under HIPAA, psychotherapy notes receive special protections that other behavioral health records do not.
What Are Psychotherapy Notes?
“Psychotherapy notes” are a very narrowly defined set of notes that exist only if the notes meet two requirements: (1) they may contain only the therapist’s impressions and analysis of what was said in a counseling session; and (2) they must be “separated from the rest of the individual’s medical record.” The psychotherapy notes protections described below apply only when both requirements are met.
As to the first requirement, psychotherapy notes are limited to the clinician’s impressions and reflections during a session as opposed to clinical facts or treatment details. They do not include things like medications, start and stop times, treatment modalities, diagnoses, progress notes or the treatment plan.
With respect to the second requirement, psychotherapy notes must be maintained separately from the rest of the record. This can be a challenge in an electronic health record (EHR) system unless the EHR is set up to separate those notes. If they are stored with other clinical records or if they are accessible to clinicians or staff other than the originator (with very limited exceptions), they lose protected status and become subject to standard HIPAA access and disclosure rules.
How are Psychotherapy Notes Treated Differently?
Psychotherapy notes are excluded from a patient’s right of access. This important protection allows clinicians to record their personal impressions and analysis for their own use without concern that the patient will have access to those notes or that they will otherwise be shared.
For most other uses and disclosures, HIPAA generally requires the patient’s written authorization before psychotherapy notes may be used or disclosed. This includes disclosure to another provider. There are a few limited exceptions. For treatment, payment, or health care operations, no authorization is required when:
- The originator of the notes uses them for treatment purposes.
- The supervisor of a student, trainee or practitioner under supervision uses or discloses the notes solely for training purposes.
- The provider uses the notes in defending itself against a legal action brought by the patient.
Other uses or disclosures that do not require authorization include those made for mandatory reporting of abuse or neglect, or to avert a serious and imminent threat of harm.
Finally, because psychotherapy notes receive these heightened protections, they should never be released in response to standard medical records requests or shared through Health Information Exchanges (such as Connie in Connecticut).
Practical Tips for Providers
Keeping psychotherapy notes properly segregated can be challenging, especially in integrated care environments and in group or clinic practices using an EHR not specifically designed for the protection of psychotherapy notes.
To ensure that the additional protections of psychotherapy notes apply:
- Segregate psychotherapy notes in a clearly designated area: Use distinct folders within the EHR for psychotherapy notes, with access restricted solely to the originator of that note.
- If your EHR cannot limit access, consider maintaining psychotherapy notes offline – paper is still an option so long as it is securely stored.
- Train staff on qualifying content for psychotherapy notes versus the clinical and treatment details in standard progress notes.
The Bottom Line
Psychotherapy notes are meant to support the therapeutic process, not the medical record. Ensuring that the content qualifies as a psychotherapy note and keeping them properly segregated will ensure that the psychotherapy notes protections apply and will ultimately help to preserve the therapeutic relationship.