The nature and extent of the record will vary depending upon the purpose, setting, and context of the psychological services. State and federal laws, as well as the American Psychological Association's (APA, 2002b) "Ethical Principles of Psychologists and Code of Conduct" (hereafter referred to as the Ethics Code), generally require maintenance of appropriate records of psychological services. This is the only way to make sure you’re staying HIPAA compliant and avoiding the hefty sanctions that can come with accidentally exposing PHI.These guidelines are designed to educate psychologists and provide a framework for making decisions regarding professional record keeping. No matter how you take psychotherapy notes, you need to put the same protections in place for them that you do for medical records. If you do work with such a service provider, make sure you have a signed BAA with them. This may mean hiring a third-party shredding service. When you destroy psychotherapy notes for patients who you haven’t seen in years, according to medical record retention laws, make sure that there is no way for someone to piece them back together. For example, after each session, you might tear the pages containing the notes off the notepad and store them in a locked filing cabinet so that no one else can access them. If you’re taking notes on paper, you also need to take precautions to safeguard them. You also need to encrypt any electronic information and enter into a business associate agreement (BAA) with your software providers, including cloud storage providers. You must conduct a complete risk analysis to identify any potential gaps in your security procedures - including training for staff. However, you must prevent anyone else from reading the notes, so you should follow the same HIPAA guidelines you would use for any other PHI.Īll the HIPAA protections that apply to medical records also apply to psychotherapy notes. You can write them by hand on a notepad or type them on a computer - as long as you keep them separate from the patient’s medical record or progress notes. Under HIPAA, psychotherapy providers don’t have to keep notes. These permitted disclosures are for the purposes of therapists defending themselves in court, cooperating with a Department of Health and Human Services (HHS) investigation, notifying appropriate parties if public health and safety is threatened, or assisting a medical examiner or coroner. There are only a few very rare reasons for a mental health professional to disclose psychotherapy notes. Staying HIPAA compliant with psychotherapy notes For example, a psychiatrist also treating the patient may request a diagnosis from the therapist, or a caregiver may need information on the medication that the patient is taking. However, a mental health professional may, upon request, share information like a diagnosis or patient’s progress. They are also unlikely to be shared with anyone. HIPAA likely calls for stricter protection of psychotherapy notes because they are the therapist’s personal notes and can contain incredibly sensitive information. An individual can access protected health information (PHI) as long as the information isn’t psychotherapy notes. HIPAA protections for psychotherapy notesĪnother important distinction HIPAA makes between psychotherapy notes and regular medical records is the right to access them. They also don’t include a diagnosis summary, the treatment plan, or the progress the patient has made. Psychotherapy notes don’t include things like medication information, the counseling session start and stop times, what types of treatments are used, and the results of clinical tests. Essentially, the notes are just about what the patient says and nothing else. ![]() ![]() These notes are separate from the patient’s medical record. ![]() HIPAA defines “psychotherapy notes” as any note taken by a mental health professional during an individual or group counseling session that the professional may refer to later. The HIPAA definition of “psychotherapy notes” Speed up the way you collect patient information by doing it online with Jotform! Create HIPAA-compliant online forms to keep patient health data protected.
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