Psychotherapy notes are considered Protected Health Information (PHI) but with a specific distinction: they are generally not used for treatment or other healthcare functions beyond the therapist who created them.
As a mental health professional, you might be accustomed to writing progress notes after a therapy session. While there are various types of documentation, not all are the same. Process notes, often resembling reflective journals, differ from progress notes. Psychotherapy notes have specific requirements under HIPAA law. Understanding what to include in these notes and what to omit is crucial for both your and your clients’ protection. Psychotherapy notes, which often include your feelings, reflections, and observations, are meant for your benefit to enhance your therapeutic effectiveness. Although this information may not always be factual, it helps improve client treatment. It’s important to keep these notes private and secure due to their special legal protections.
Psychotherapy Notes and PHI
Psychotherapy notes are private notes that mental health clinicians often keep for themselves. They serve as reminders, contain questions for supervision, or include general observations and feelings about the therapy session. These notes are intended solely for the therapist’s benefit.
Psychotherapy notes are sometimes referred to as process notes. Unlike progress notes, which are part of the client’s official medical record, there is no requirement or specific format for keeping psychotherapy notes. It’s crucial to differentiate between psychotherapy notes and progress notes.
Protected Health Information (PHI) in medical documentation includes any data that can identify a client and is created, used, or disclosed during healthcare services. According to the Department of Health and Human Services, potential identifiers of PHI include:
Name
Geographic divisions smaller than a state
Phone numbers
Fax numbers
Dates (e.g., birth, admission, discharge)
Medical record numbers
Health plan beneficiary numbers
Email addresses
Certificate/License numbers
Photos (including full-face photos)
Biometric identifiers (e.g., fingerprints)
Zip codes
Vehicle identifiers
URLs
Social security numbers
Account numbers
Device identifiers and serial numbers
IP addresses
Psychotherapy notes are not part of the client’s official medical record and typically contain minimal PHI. These notes often reflect the therapist’s personal thoughts, so it’s important to keep them secure. Psychotherapy notes have special protections under the Health Insurance Portability and Accountability Act (HIPAA).
Recommended Reading: The Best Mental Health Therapy Progress Note Generator
HIPAA and Psychotherapy Notes
HIPAA provides additional protections to limit the release of psychotherapy notes. According to the Department of Health and Human Services, these notes have special protections because they are kept by the clinician for their benefit. HIPAA requires client consent and authorization before releasing psychotherapy notes to anyone other than the clinician who wrote them.
The HIPAA Privacy Rule defines psychotherapy notes as follows:
“Psychotherapy notes means 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 and that are separated from the rest of the individual’s medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.”
Additionally, the HIPAA Privacy Rule states:
“Psychotherapy notes are treated differently from other mental health information both because they contain particularly sensitive information and because they are the personal notes of the therapist that typically are not required or useful for treatment, payment, or health care operations purposes, other than by the mental health professional who created the notes. Therefore, with few exceptions, the Privacy Rule requires a covered entity to obtain a patient’s authorization prior to a disclosure of psychotherapy notes for any reason, including a disclosure for treatment purposes to a health care provider other than the originator of the notes. See 45 CFR 164.508(a)(2). A notable exception exists for disclosures required by other law, such as for mandatory reporting of abuse, and mandatory ‘duty to warn’ situations regarding threats of serious and imminent harm made by the patient (State laws vary as to whether such a warning is mandatory or permissible).”
This means that to disclose psychotherapy notes to anyone, you must have authorization from the client. Ideally, these notes are kept private for the clinician’s benefit and should be released only in legally required situations, such as abuse reporting.
What to Keep in Psychotherapy Notes
Psychotherapy notes are intended for the clinician’s benefit. These notes may include:
Observations about the client: Personal insights or thoughts about the client’s behavior or statements during the session.
Questions for consultation or supervision: Points to discuss with colleagues or supervisors for further guidance.
Hypotheses about the client: Theories or ideas about the client’s issues or behaviors that might need further exploration.
These notes should not include details directly related to the client’s treatment, as they are meant for your personal use. You might jot down something to revisit later or highlight a topic requiring additional consultation or supervision. Psychotherapy notes are private and not part of the client’s official medical record.
You might also note issues or information that emerged during the session for which you need more training. These notes help you enhance your therapeutic approach and better treat your client.
When writing process notes, the focus is less on treatment details and more on the therapy process. For example, if you notice strong personal feelings that you want to discuss with your supervisor, documenting these in a process note can be appropriate. Such feelings may be unsuitable for the client’s official medical record but are useful for your personal reflection.
There isn’t a strict format for process notes, which often resemble journal entries. You might document your thoughts and feelings regarding the client. Some suggest writing these notes anonymously and excluding any Protected Health Information (PHI) to ensure privacy, as a judge can order their release in specific situations. Your comfort level should guide what you include in psychotherapy notes.
If you’re unsure about what to include, consider seeking consultation, speaking with your licensing board, or contacting your liability insurance provider for guidance.
What to Keep Out of Psychotherapy Notes
Certain information should be excluded from psychotherapy notes, as these notes are not part of the client’s medical record. Here’s what should not be included:
Medication prescription and monitoring
Start and stop times of psychotherapy sessions
Treatment modalities used
Results of any clinical tests or assessments
Diagnosis
Functional status
Treatment plan
Prognosis
Symptom description
Any overview of the client’s progress
Treatment summaries
This information should be documented in mental health progress notes, which are part of the client’s official medical record. Psychotherapy notes should also exclude any details regarding the payment of healthcare services, as process notes do not typically contain information about treatment, payment, or business operations.
Streamline Psychotherapy Notes with S10.AI
Therapists often keep personal notes on their sessions, but these are distinct from official medical records. There’s no legal requirement to create these notes, nor is there a standardized format.
S10.AI steps in to revolutionize this process. This AI medical scribe software helps therapists capture session details in real-time, freeing them from lengthy post-session note-taking.
Here’s how S10.AI empowers therapists:
Focus on the Client: By automating note-taking, therapists can stay present and fully engaged with their clients during sessions.
Enhanced Accuracy: S10.AI utilizes advanced technology to capture nuances of the conversation, including nonverbal cues, leading to more comprehensive notes.
Improved Efficiency: Eliminate the burden of post-session documentation. S10.AI allows therapists to focus on their core tasks – providing quality care to their clients.
Confidentiality Remains Paramount:
These notes, generated with S10.AI or otherwise, are strictly confidential. They are never shared with anyone, including insurance companies, without the client’s explicit consent. Therapists can customize S10.AI to minimize the inclusion of Protected Health Information (PHI) for maximum client privacy.
The Choice to Reflect:
While not mandatory, therapists can leverage these notes for self-reflection and growth. Analyzing session dynamics and personal reactions with S10.AI can provide valuable insights for enhancing their therapeutic approach.
