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Based on
an informal poll it appears most psych professionals do not create or maintain
the sorts of notes that are defined by HIPAA as “psychotherapy notes”. The HIPAA
exception evidently arose out of requests for special protection by those few
professionals who do create such notes.
Not all “schools” of psychiatry and psychology promote the concept but
those who are of that discipline consider such notes their own property for
their sole use and – obviously – not part of the patient record. One doc I spoke with describes his “psychotherapy
notes” as his ‘little black book’.
In it he jots down his informal impressions during patient sessions,
usually using a sort of personal shorthand and not identifying patients by
name. His chronological series of ‘little
black books’, which contain notes on virtually all patients, is locked in his
desk drawer. Personally,
I think it makes sense for a doctor or psychotherapist to have such notes
simply as a means to retain the gist of conversations and create a reference
source for the thoughts that come to mind during a session that are not
appropriate for inclusion in the actual record. It likely assists them to maintain a higher level of
familiarity and, therefore, a better relationship with each patient. I just
wish the authors of HIPAA had used a term to identify such notes that would create
less confusion. As an example of
the degree of misunderstanding, about a year ago I asked a HIPAA
beginner/intermediate level seminar audience from facilities with psych units
whether their clinicians created psychotherapy notes. All raised their hands. After a detailed explanation of the true HIPAA definition of
psychotherapy notes I asked the question again. No one raised their hands. It is possible, though, that some were just unaware of the
existence of such notes in their facility. I have it on good authority that there are some psychotherapists
who keep such notes but simply do not make it known, and frankly, there’s no
reason they should. As I
understand the concept, such notes are virtually useless to anyone but the
author. However, I’ve decided that
as a precaution we will include in our role-based training for the psych
clinicians the requirement that if they do create such notes that they do so in
a manner that is as “unidentifiable” as possible, maintain them securely, and
destroy them as soon as practicable. Cheri
Huber County
Privacy Officer County of
Napa 1195 Third
Street, Room 301 Napa,
CA 94559 707-253-4523 -----Original
Message----- Psychotherapy notes
are defined very specifically in the regulations including that the
records "are separated from the rest of the individual's medical
record." Does the definition imply
that a mental health provider who does not keep the records separate --
not have HIPAA psychotherapy notes? If so, can the provider release
the records under a general HIPAA authorization and not be required to obtain a
separate authorization for release of what may be classified as "psychotherapy
notes" had such records been kept separate and apart from the other
medical records. Basically was the
definition designed to allow two ways to handle such records. It is my
understanding from discussion with some mental health care providers that they
like to keep some records separate and from others that they put all the
records into the full medical record. Thoughts. bob coffield ****************************************************** ******************************************************* --- The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. These listservs should not be used for commercial marketing purposes or discussion of specific vendor products and services. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time. You are currently subscribed to wedi-privacy as: [EMAIL PROTECTED] To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED] If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org |
- Psychotherapy Notes Coffield, Robert L.
- RE: Psychotherapy Notes Huber, Cheri
- RE: Psychotherapy Notes Coffield, Robert L.
- RE: Psychotherapy Notes Huber, Cheri
- Re: Psychotherapy Notes DKHGRMI
- RE: Psychotherapy Notes Matthew Rosenblum
- RE: Psychotherapy Notes Huber, Cheri
