Response: In the final rule, we continue to use the term “counseling” in the definition of “psychotherapy.” During our fact-finding, we learned that “counseling” had no commonly agreed upon definition, but seemed to be widely understood in practice. It does not refer to the medical record and other sources of information that would normally be disclosed for treatment, payment, and health care operations.Ĭomment: One commenter was particularly concerned that the use of the term “counseling” in the definition of psychotherapy notes would lead to confusion because counseling and psychotherapy are different disciplines. Although all psychotherapy information may be considered sensitive, we have limited the definition of psychotherapy notes to only that information that is kept separate by the provider for his or her own purposes. Information in these notes is not intended to communicate to, or even be seen by, persons other than the therapist. Response: As discussed above and in the NPRM, the rationale for providing special protection for psychotherapy notes is not only that they contain particularly sensitive information, but also that they are the personal notes of the therapist, intended to help him or her recall the therapy discussion and are of little or no use to others not involved in the therapy. They claimed that this information is highly sensitive and should not be released without the individual’s written consent, except in cases of emergency…. Information from the medical record is routinely sent to insurers for payment.Ĭomment: … Many commenters believed that the psychotherapy notes should include frequencies of treatment, results of clinical tests, and summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date. These separate “process notes” are what we are calling “psychotherapy notes.” Summary information, such as the current state of the patient, symptoms, summary of the theme of the psychotherapy session, diagnoses, medications prescribed, side effects, and any other information necessary for treatment or payment, is always placed in the patient’s medical record. We were told that process notes are often kept separate to limit access, even in an electronic record system, because they contain sensitive information relevant to no one other than the treating provider. These notes are often referred to as “process notes,” distinguishable from “progress notes,” “the medical record,” or “official records.” These process notes capture the therapist’s impressions about the patient, contain details of the psychotherapy conversation considered to be inappropriate for the medical record, and are used by the provider for future sessions. Response: We conducted fact-finding with providers and other knowledgeable parties to determine the standard practice of psychotherapists and determined that only some psychotherapists keep separate files with notes pertaining to psychotherapy sessions. They claimed that reports of psychotherapy are typically part of the medical record and that psychologists are advised, for ethical reasons and liability risk management purposes, not to keep two separate sets of notes…. The 2000 commentary explains the reason for this rule along with HHS’s practical view of what constitutes “psychotherapy notes”:Ĭomment: Some commenters thought the definition of psychotherapy notes was contrary to standard practice. To be considered “psychotherapy notes”, the notes must be separate from the medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. The HIPAA privacy rules give special protection to “psychotherapy notes,” but providers often misunderstand what are and are not covered and how they differ from other mental health records.Ĭontrary to popular belief, HIPAA does not provide special protection to mental health records in general, but it does give added protection to “psychotherapy notes”.
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