Confidentiality, Privacy and Security

Psychotherapy notes

  • 1.  Psychotherapy notes

    Posted 22 days ago

    Good Morning and almost Happy New Year!

    I work for an FQHC.  We provide medical, dental, vision and behavioral health services.  Each department shares the same software for documentation and billing.  We use eClinicalWorks.  I am wondering how others are planning/preparing for the changes coming down the road in regards to patient access to their information via third party apps and the information blocking rules.

    Our behavioral health providers document their encounters in the software system.  We do have a system/process in place that limits employee access to those encounter notes.  I am trying to determine if what these providers document would be considered "process notes" or "progress notes". In an article written by Ruby Nicholson, RHIT in the Journal:

    "However, the privacy regulations are clear that only those psychotherapy notes kept separate from the rest of the individual's record are afforded additional protection. All psychotherapy notes maintained with other documentation lose any special protection for confidentiality and are not required to be treated differently."

      Article citation:
    Nicholson, Ruby. "The Dilemma of Psychotherapy Notes and HIPAA." Journal of AHIMA 73, no.2 (2002): 38-39.

    I am trying to determine if what our mental health providers are documenting would be classified as "psychotherapy notes".  From what I have been reading/researching, there are two types of documentation for mental health providers.  "Process notes", aka psychotherapy notes, which are the providers own personal thoughts, plans, evaluations, etc... these are the notes that are to be kept separate and therefore have special protection. The second type are "progress notes" which are not considered as protected under HIPAA, unless they are related to substance abuse. These notes generally include information such as the start/stop time, who was in the session, a diagnosis, testing results, medications and  treatment plans.  Mental health providers may interpret both as "psychotherapy notes".

    Is anyone out here having the same dilemma?

    Thanks for any input, I learn so much following these discussions.



    ------------------------------
    Cindy Goering
    Him Supervisor/Coder/Credentialing Coordinator
    ------------------------------



  • 2.  RE: Psychotherapy notes

    Posted 21 days ago

    Hello Cindy,

     

    Here is a link to a more current (2020) article that helps to clarify psychotherapy notes (by definition) , and the difference between progress notes v process notes that you may find helpful. 

     

    https://www.hollandhart.com/hipaa-psychotherapy-notes-and-other-mental-health-records

     

    Elizabeth Taylor, MS, RHIT, CHC

    Chief Compliance Officer, DMHAS

     




    This correspondence contains proprietary information some or all of which may be legally privileged; it is for the intended recipient only. If you are not the intended recipient you must not use, disclose, distribute, copy, print, or rely on this correspondence and completely dispose of the correspondence immediately. Please notify the sender if you have received this email in error. NOTE: Messages to or from the State of Connecticut domain may be subject to the Freedom of Information statutes and regulations.






  • 3.  RE: Psychotherapy notes

    Posted 21 days ago
    Thank You Elizabeth, I appreciate the help!

    ------------------------------
    Cindy Goering
    Him Supervisor/Coder/Credentialing Coordinator
    ------------------------------



  • 4.  RE: Psychotherapy notes

    Posted 21 days ago
    Here is article that I found insightful!

    https://www.jdsupra.com/legalnews/hipaa-psychotherapy-notes-and-other-42359/


    ------------------------------
    Lori Black, RHIA, CCS, CHTS-IM
    HIM Director
    INTEGRIS Health
    ------------------------------



  • 5.  RE: Psychotherapy notes

    Posted 21 days ago
    Thank you Lori!  I appreciate the help

    ------------------------------
    Cindy Goering
    Him Supervisor/Coder/Credentialing Coordinator
    ------------------------------