Paulette,
Among most behavioral
health professionals "process" notes (referred to by HIPAA as "psychotherapy"
notes) are those pieces of documentation that therapists write, basically for
their own use, to remind themselves of what the patient has said, for example,
the content of a dream, or the experience of guilt associated with a
"forbidden" feeling. HHS has given us the opportunity to strictly limit
the availability of this information by providing a higher order of protection
for these "process" notes, and with few exceptions, disclosures may be made
only if the CE obtains a signed-authorization.
Under HIPAA
psychotherapy notes are defined as those notes:
1) Recorded 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, and,
2) Maintained
separate from the medical record, and
3) That
exclude:
a. Medication
prescription and monitoring
b. Counseling session
start and stop times
c. The modalities and
frequencies of treatment furnished
d. Results of
clinical tests
e. Any summary of
diagnosis, functional status, the treatment plan, symptoms, prognosis, and
progress to date
Note, that #3 (above)
delineates most of the information that we normally put into our "progress
notes" to substantiate treatment, and consequently, we must separate that
information from the "psychotherapy or process notes" (that is, if we want to
further protect the "process" information.)
So, under HIPAA,
"psychotherapy notes" must be SEPARATED from the rest of the record if they
are to be afforded the additional protections provided by the Privacy
Rules. In the “paper” world, this probably means the “psychotherapy
notes” should remain under the lock-and-key of the writer of the note.
In the “electronic” world, user ID and password protections would probably be
the minimum.
I hope that this
helps.
Your questions are
always welcome.
Matt
Matthew
Rosenblum
Chief Operations
Officer
Privacy, Quality
Management & Regulatory Affairs
http://www.CPIdirections.com
CPI
Directions, Inc.
10 West 15th Street,
Suite 1922
New
York, NY
10011
(212)
675-6367
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-----Original
Message-----
From:
[EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]
Sent: Tuesday, March 18,
2003 4:11
PM
To: WEDI SNIP Privacy Workgroup
List
Subject: psych
notes
Our practice is family
practice. We contract in a LCSW who uses our charts for her progress
notes. I understand that mental health is handled differently than that
of a PCP as far as authorizations for release of info. (we need specific auth
to release). I also remember reading somewhere that mental health needs
to be "seperately identifiable" in the chart. Can someone help me out
with this? We do not have a seperate divider in the chart for mental
health however we do have the LCSW use blue progress notes. This seems
reasonable to me to satisfy the "seperately identifiable". Any words of
advise?
Paulette Ortega
Practice Administrator
Comprehensive
Family Care Center
2002 Lake Ave., Ste. D
Pueblo, CO
81004
(719) 562-1122 ---
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