Documenting Psychotherapy Notes
This may not be applicable to all Allied Health professionals. However, to the extent that you document psychotherapy notes or interact with professionals who do, there are a number of factors to keep in mind. Psychotherapy notes are discussed in HIPAA. Psychotherapy notes are notes recorded by a behavioral health professional documenting/analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes do not include information about medications, start and stop times, treatments, results of clinical tests, summary of diagnosis, functional status, treatment plans, symptoms, prognosis, and progress.  They are the personal notes of the provider and differ from progress notes which are part of the medical record.
Psychotherapy notes are afforded a higher level of protection from disclosure than non-psychotherapy documentation under HIPAA. However, they must be kept separate from the medical record. If they are intertwined, they lose that level of protection. If you are documenting in written format, keep psychotherapy notes separate from the record. This may be problematic as some EMR systems do not have the capability to separate out psychotherapy notes from the record. When using an EMR, be aware if the notes are separate or not. If your EMR system does not have the ability to separate out psychotherapy notes, keep separate written or electronic psychotherapy notes. If in electronic form, ensure they are safe, secure, and encrypted. If they are kept in written form, ensure they are secure and kept in a locked location. If you are unable to do either, you may consider not documenting psychotherapy notes in addition to the documentation in the patient’s medical record. Even if you do not document psychotherapy notes, you may be a professional who requests a record from another professional who does.
Be aware if your state has a specific rule on psychotherapy notes as it could differ from the HIPAA rule. Check your profession’s ethical guidelines on documentation principles. When you have questions, it is best to consult an attorney for guidance.
Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM
Healthcare Practice and Risk Management Innovation Officer
Trust Risk Management Services, Inc.
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