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Psychotherapy Notes: Difference between revisions
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'''Psychotherapy notes''' are notes recorded (in any medium) by a licensed mental health practitioner (LMHP) documenting or analyzing the contents of a conversation during a private counseling session or group, joint, or family counseling session. Psychotherapy notes are kept separate from the rest of the individual’s medical record. Psychotherapy notes are sometimes referred to as “process notes”. Psychotherapy notes excludes 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. Psychotherapy notes are not progress notes, and are created at the discretion of the LMHP. (HIPAA: 45 CFR §164.501) | '''Psychotherapy notes''' are notes recorded (in any medium) by a licensed mental health practitioner (LMHP) documenting or analyzing the contents of a conversation during a private counseling session or group, joint, or family counseling session. Psychotherapy notes are kept separate from the rest of the individual’s medical record. Psychotherapy notes are sometimes referred to as “process notes”. Psychotherapy notes excludes 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. Psychotherapy notes are not progress notes, and are created at the discretion of the LMHP. (HIPAA: 45 CFR §164.501) | ||
For more information, contact | For more information, contact Deb Bishop, Privacy Officer, or see Psychotherapy Notes Procedures. | ||
Psychotherapy Notes Procedures | Psychotherapy Notes Procedures | ||