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Psychotherapy Notes: Difference between revisions
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<big>'''Psychotherapy Notes Policy'''</big><br /> | <big>'''Psychotherapy Notes Policy'''</big><br /> | ||
== Basis for Policy == | == Basis for Policy == | ||
It is the policy of University of Nebraska Medical Center (UNMC) to maintain strict confidentiality of psychotherapy notes to ensure the privacy of sensitive patient information and comply with [https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] requirements. | It is the policy of the University of Nebraska Medical Center (UNMC) to maintain strict confidentiality of psychotherapy notes to ensure the privacy of sensitive patient information and comply with [https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] requirements. | ||
==Policy == | ==Policy == | ||
UNMC shall maintain strict confidentiality of psychotherapy notes to ensure the privacy of sensitive patient information and to comply with Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements, [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf University of Nebraska Executive Memorandum No. 27] and UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]]. | UNMC shall maintain strict confidentiality of psychotherapy notes to ensure the privacy of sensitive patient information and to comply with Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements, [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf University of Nebraska Executive Memorandum No. 27] and UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]]. | ||
== Procedures== | == Procedures== | ||
Psychotherapy notes are created by a mental | Psychotherapy notes are created by a mental health care provider for their own use during the course of patient treatment. These process notes may capture the provider’s impressions about the Individual or may contain details about psychotherapy content considered to be inappropriate for the medical record and are used by the provider for future sessions. <br /> | ||
Psychotherapy notes shall be stored in a secure location and may be destroyed at the discretion of the author when no longer needed. However, when a mental health care provider terminates employment/affiliation with UNMC or UNMC Physicians, they must destroy all psychotherapy notes related to | Psychotherapy notes shall be stored in a secure location and may be destroyed at the discretion of the author when no longer needed. However, when a mental health care provider terminates employment/affiliation with UNMC or UNMC Physicians, they must destroy all psychotherapy notes related to Individuals receiving care at these entities upon departure. Psychotherapy notes shall not be maintained in the medical record. | ||
===Use or Disclosure of Psychotherapy Notes=== | ===Use or Disclosure of Psychotherapy Notes=== | ||
Psychotherapy notes may be used and disclosed for the following purposes only: | Psychotherapy notes may be used and disclosed for the following purposes only: | ||
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:All other uses and disclosures of psychotherapy notes are prohibited unless the subject of the psychotherapy note signs an authorization. Authorizations for the use or disclosure of psychotherapy notes may be combined only with another authorization for the use or disclosure of psychotherapy notes. Authorizations for the use or disclosure of psychotherapy notes may not be combined with an authorization for any other Protected Health Information (PHI).<br /> | :All other uses and disclosures of psychotherapy notes are prohibited unless the subject of the psychotherapy note signs an authorization. Authorizations for the use or disclosure of psychotherapy notes may be combined only with another authorization for the use or disclosure of psychotherapy notes. Authorizations for the use or disclosure of psychotherapy notes may not be combined with an authorization for any other Protected Health Information (PHI).<br /> | ||
Individuals who are the subject of the psychotherapy note do not have the right to access the psychotherapy note. Psychotherapy notes may be released to the Individual only with the author's approval and in a format, a summary for example, similarly approved by the originator. An Individual does not have a right to review the originator’s denial of access. | |||
== Definitions == | == Definitions == | ||
===Individual=== | ===Individual=== | ||
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*an Individual’s genetic tests; | *an Individual’s genetic tests; | ||
*the genetic tests of an Individual’s family members; or | *the genetic tests of an Individual’s family members; or | ||
*the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history) | *the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history). | ||
PHI excludes: | PHI excludes: | ||
*individually identifiable health information of a person who has been deceased for more than fifty (50) years. | *individually identifiable health information of a person who has been deceased for more than fifty (50) years. | ||