Do you REALLY know what psychotherapy notes are?

“Notes about Psychotherapy” versus “Psychotherapy Notes”

photo credit: Sikkema cc

photo credit: Sikkema cc

A therapist spoke to me recently, concerned because an insurance company wanted more patient information than she felt was typical for the situation. She asked:

“Isn’t it true that HIPAA provides special protection for psychotherapy notes?”

The answer is yes, but…  this doesn’t mean what most therapists think it does.   “Psychotherapy notes” is now a technical term, thanks to HIPAA, which codified two types of notes a therapist might keep: “progress notes” and “psychotherapy notes.”

In the past, without a legal definition, I think we assumed that if a psychotherapist (of any credential) wrote the note, then it was a psychotherapy note. This is not the case anymore. A licensed mental health provider may write the note, and it may contain sensitive mental health information, but that is not enough to get the note special privacy protections under HIPAA. Let me explain further:

Progress notes

Progress notes are the type of note that 100% of therapists have. Why? Because this is the default type of note, and you can’t have any other kind of note without also having “progress notes.” A progress note might include information like:

  • Diagnosis
  • Status
  • Treatment plan
  • Modality of treatment
  • Frequency of treatment
  • Symptoms
  • Prognosis
  • Progress
  • Tests
  • Medications
  • Scheduling Information
  • Information critical to treatment

If you’re like me, the first time I read that list I wondered “What’s left!?!” The answer is: not much. By my own unofficial math, progress notes include about 99% of what I might document about a client. But. Sometimes there is a little more, which brings us to…

Psychotherapy notes

Sometimes a therapist might document the contents of a conversation from a session.  Perhaps we want to record our own professional analysis of the conversation; notes to help us recall the conversation, notes to help ourselves next time. That is the sort of information that HIPAA says belongs in a “psychotherapy note,” and THAT is what we can claim some special protection for, assuming we jump through some other hoops first.

Hoop #1: Do you have two sets of notes?

(If no, you can’t have psychotherapy notes. Only one set of notes=progress notes.)

Hoop #2: Are your psychotherapy notes kept separately from the rest of the medical record?

(If no, you don’t have psychotherapy notes.)

Hoop #3: Are you documenting important relevant information (like diagnosis, status, treatment, modality, prognosis, progress, etc.) in the progress notes?

(If no, your progress notes aren’t sufficient to merit a second set of protected psychotherapy notes. Information critical to treatment must be included in progress notes.)

Hoop #4: Do your psychotherapy notes contain information like: thoughts for your own use, documentation or analysis of the conversations or interactions, impressions (not dx) of your client, information that really wouldn’t be helpful anyone else to have because it’s just for your own use?

If you’ve answered yes to everything, you probably have psychotherapy notes that merit some special protection under HIPAA. If you didn’t say yes to everything, you probably don’t.

So, to sum it all up: just because a psychotherapist writes a note about a session doesn’t make it a psychotherapy note. Most of the information a therapist documents about a session will probably belong in the part of the file that is accessible (with appropriate consent) to other providers, insurance companies, etc.  Your psychotherapy notes, if you have jumped through the hoops to be able to claim that you really have them–are limited in scope and usefulness (they are just for you) but do receive special privacy protection under HIPAA.

**********

PS.  Friendly Reminder: I’m not an attorney and this article (nor anything else on this website) is legal advice.  Consult your attorney for advice on your particular situation.

 

This page has a ton of information about what HIPAA says about psychotherapy notes.