Psychotherapy Notes

• California law offers stronger privacy protections for mental health than the Privacy Rule. When requests for release of information for mental health records are made, inclusive of but not limited to psychotherapy notes, forward the request to the HIM Department.

Under the Privacy Rule, a covered entity must obtain an authorization for any use or disclosure of psychotherapy notes with the following exception:

• For use purposes only by the originator of the psychotherapy notes. Note: an authorization must be obtained for disclosure
• For use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling
• For use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual
• When required by the Secretary of HHS to determine the covered entity's compliance with privacy provisions;
• For use or disclosure required by law or, for health oversight activities
• For use or disclosure to a coroner and medical examiner
• If use or disclosure is necessary to lessen or prevent a serious and imminent threat to the health or safety to a person or the public

The regulations define psychotherapy notes as:

• 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
• Notes that are separated from the rest of the individual's medical record.

Notes not considered psychotherapy notes

The following are not considered psychotherapy notes. For the types of notes listed below, obtain prior written authorization for use or disclosure for purposes other than treatment, payment or health care operations. For uses or disclosures pertaining to treatment, payment or healthcare operations, follow state requirements for mental health records.

• Medication prescription and monitoring
• Counseling session start and stop times
• Modalities and frequencies of treatment furnished
• Results of clinical tests
• Summaries of the following items:
  • diagnosis
  • functional status
  • treatment plan
  • symptoms
  • prognosis
  • progress to date

Previous | TOC | Next