Psychotherapy Notes - Revision history

Afaylor: /* Additional Information */ updated Health Insurance Portability and Accountability Act of 1996 (HIPAA) link - 2x

2025-09-29T19:46:37Z

Additional Information: updated Health Insurance Portability and Accountability Act of 1996 (HIPAA) link - 2x

← Older revision		Revision as of 14:46, September 29, 2025
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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 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.		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/php/resources/health-insurance-portability-and-accountability-act-of-1996-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]].
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	*UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]]		*UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]]
	*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf University of Nebraska Executive Memorandum No. 27]		*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf University of Nebraska Executive Memorandum No. 27]
	*[https://www.cdc.gov/phlp/~~publications~~/~~topic~~/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]		*[https://www.cdc.gov/phlp/php/resources/health-insurance-portability-and-accountability-act-of-1996-hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]

	This page maintained by [mailto:mhurlocker@unmc.edu mh]		This page maintained by [mailto:mhurlocker@unmc.edu mh]

Mhurlocker at 19:34, July 24, 2024

2024-07-24T19:34:10Z

← Older revision		Revision as of 14:34, July 24, 2024
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	Policy No.: '''6066'''<br />		Policy No.: '''6066'''<br />
	Effective Date: '''03/17/03'''<br />		Effective Date: '''03/17/03'''<br />
	Revised Date: '''~~draft~~ 09/22/22'''<br />		Revised Date: '''09/22/22'''<br />
	~~Revised~~ Date: <br /><br />		Review Date: 09/22/22<br /><br />
	<big>'''Psychotherapy Notes Policy'''</big><br />		<big>'''Psychotherapy Notes Policy'''</big><br />
	== Basis for Policy ==		== Basis for Policy ==
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	*[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]		*[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]

	This page maintained by [mailto:~~dpanowic~~@unmc.edu ~~dkp~~]		This page maintained by [mailto:mhurlocker@unmc.edu mh]

Mhurlocker: /* Protected Health Information (PHI) */

2023-08-15T19:09:49Z

Protected Health Information (PHI)

← Older revision		Revision as of 14:09, August 15, 2023
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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)~~; or~~		*the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history).
	*any request for, or receipt of, genetic services (e.g., genetic test, genetic counseling, genetic education), or participation in clinical research which includes genetic services by the Individual or any family member of the Individual.
	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.

Dpanowic at 17:40, September 22, 2022

2022-09-22T17:40:15Z

← Older revision		Revision as of 12:40, September 22, 2022
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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 ~~healthcare~~ provider for ~~his/her~~ own use during the course of patient treatment. These process notes may capture the provider’s impressions about the ~~patient~~ 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 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 ~~patients~~ receiving care at these entities upon departure. Psychotherapy notes shall not be maintained in the medical record.		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 />

	~~Patients~~ 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. ~~A patient~~ does not have a right to review the originator’s denial of access.		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===

Dpanowic at 17:23, September 22, 2022

2022-09-22T17:23:09Z

← Older revision		Revision as of 12:23, September 22, 2022
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	</table>		</table>
	<br />		<br />
	[[Identification Card]] \| [[Secure Area Card Access]] \| [[Privacy/Confidentiality]] \| [[Computer Use/Electronic Information]] \| [[Retention and Destruction/Disposal of Private and Confidential Information]] \| [[Use and Disclosure of Protected Health Information]] \| [[Notice of Privacy Practices]] \| [[Access to Designated Record Set]] \| [[Accounting of PHI Disclosures]] \| [[Patient/Consumer Complaints]] \| [[Vendors]] \| [[Fax Transmissions]] \| [[Psychotherapy Notes]] \| [[Facility Security]] \| [[Conditions of Treatment Form]] \| [[Informed Consent for UNMC Media]] \| [[Transporting Protected Health Information]] \| [[Honest Broker]] \| [[Social Security Number]] \| [[Third Party Registry]] \| [[Information Security Awareness and Training]]		[[Identification Card]] \| [[Secure Area Card Access]] \| [[Privacy/Confidentiality]] \| [[Computer Use/Electronic Information]] \| [[Retention and Destruction/Disposal of Private and Confidential Information]] \| [[Use and Disclosure of Protected Health Information]] \| [[Notice of Privacy Practices]] \| [[Access to Designated Record Set]] \| [[Accounting of PHI Disclosures]] \| [[Patient/Consumer Complaints]] \| [[Vendors]] \| [[Fax Transmissions]] \| [[Psychotherapy Notes]] \| [[Facility Security]] \| [[Conditions of Treatment Form]] \| [[Informed Consent for UNMC Media]] \| [[Transporting Protected Health Information]] \| [[Honest Broker]] \| [[Social Security Number]] \| [[Third Party Registry]] \| [[Information Security Awareness and Training]] \| [[Patient Privacy Investigations and Levels of Violation]] \| [[Use and Disclosure of PHI for Training Health Care Professionals]] \| [[Disclosures of PHI as Permitted or Required by Law]] \| [[Disclosure of PHI for Law Enforcement Purposes]]
	<br /><br />		<br /><br />
	Policy No.: '''6066''<br />		Policy No.: '''6066'''<br />
	Effective Date: '''03/17/03'''<br />		Effective Date: '''03/17/03'''<br />
	Revised Date: <br />		Revised Date: '''draft 09/22/22'''<br />
	Revised Date: <br /><br />		Revised Date: <br /><br />
	<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 ~~protect~~ confidentiality ~~and~~ privacy ~~through appropriate use~~ of information ~~gathered in the course~~ of ~~employment or other affiliation with UNMC or entrusted to UNMC for academic, research, patient care, or administrative purposes~~.		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.
	=== 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, 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]].
	==~~= Definitions =~~==		== Procedures==
			Psychotherapy notes are created by a mental healthcare provider for his/her own use during the course of patient treatment. These process notes may capture the provider’s impressions about the patient 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 />

	~~'''Privacy''' is defined~~ as the ~~right~~ of ~~individuals~~ to ~~keep information about themselves from being disclosed~~.		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 patients receiving care at these entities upon departure. Psychotherapy notes shall not be maintained in the medical record.
			===Use or Disclosure of Psychotherapy Notes===
			Psychotherapy notes may be used and disclosed for the following purposes only:
			*Use by the mental health care provider who created the notes for treatment;
			*Use by The Nebraska Medical Center for its own training programs in which students, trainees or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family or individual counseling;
			*Use or disclosure for purposes of defense in a legal action or other proceeding brought by the subject of the note;
			*Disclosure to coroners and medical examiners to perform their duties as required by law;
			*Disclosure to state agencies responsible for oversight of the originator of the note (i.e. state licensing boards, etc.);
			*Disclosure required by federal law or Nebraska state law (i.e. child abuse investigations, court order, etc.); or
			*Disclosure necessary to avert imminent threat to the health and safety of a person or the public.
			: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 />

	~~'''~~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)		Patients 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. A patient does not have a right to review the originator’s denial of access.
			== Definitions ==
			===Individual===
			The person who is the subject of the PHI. Personal representatives of the Individual have the same rights as the Individual under HIPAA (i.e., they “step into the shoes” of the Individual). Personal representatives include the legal guardian and anyone else authorized by law to act on behalf of the Individual. (See Nebraska Medicine Consents and Permits policy, MS14.)
			===Protected Health Information (PHI)===
			Individually identifiable health information including demographic information, collected from an Individual, whether oral or recorded in any medium, that:
			*is created or received by UNMC/ACE; and
			*relates to the past, present or future physical or mental health or condition of an Individual; the provision of health care to an Individual; or the past, present or future payment for the provision of health care to an Individual and identifies the Individual or with respect to which there is a reasonable basis to believe the information can be used to identify the Individual.
			PHI includes genetic information, which includes information about the following items (and excludes information about an Individual’s sex or age):
			*an Individual’s genetic tests;
			*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); or
			*any request for, or receipt of, genetic services (e.g., genetic test, genetic counseling, genetic education), or participation in clinical research which includes genetic services by the Individual or any family member of the Individual.
			PHI excludes:
			*individually identifiable health information of a person who has been deceased for more than fifty (50) years.
			*education records covered by the Family Educational Rights and Privacy Act (FERPA); and
			*employment records held by UNMC in its role as employer.
			===Psychotherapy Notes===
			Notes recorded (in any medium) by a mental health provider including psychiatrists, psychologists and other mental health professionals 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 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. Psychotherapy notes are not progress notes and are created at the discretion of the mental health care provider. (HIPAA: 45 CFR §164.501)

	===Additional Information===		===Additional Information===
	*Contact [mailto:dbishop@unmc.edu Privacy Officer]		*Contact [mailto:dbishop@unmc.edu Privacy Officer]
	*~~See Psychotherapy Notes Procedures~~		*UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]]
			*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf University of Nebraska Executive Memorandum No. 27]
			*[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]

	This page maintained by [mailto:dpanowic@unmc.edu dkp]		This page maintained by [mailto:dpanowic@unmc.edu dkp]

Dpanowic at 21:56, February 18, 2020

2020-02-18T21:56:48Z

← Older revision		Revision as of 16:56, February 18, 2020
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	[[Identification Card]] \| [[Secure Area Card Access]] \| [[Privacy/Confidentiality]] \| [[Computer Use/Electronic Information]] \| [[Retention and Destruction/Disposal of Private and Confidential Information]] \| [[Use and Disclosure of Protected Health Information]] \| [[Notice of Privacy Practices]] \| [[Access to Designated Record Set]] \| [[Accounting of PHI Disclosures]] \| [[Patient/Consumer Complaints]] \| [[Vendors]] \| [[Fax Transmissions]] \| [[Psychotherapy Notes]] \| [[Facility Security]] \| [[Conditions of Treatment Form]] \| [[Informed Consent for UNMC Media]] \| [[Transporting Protected Health Information]] \| [[Honest Broker]] \| [[Social Security Number]] \| [[Third Party Registry]] \| [[Information Security Awareness and Training]]		[[Identification Card]] \| [[Secure Area Card Access]] \| [[Privacy/Confidentiality]] \| [[Computer Use/Electronic Information]] \| [[Retention and Destruction/Disposal of Private and Confidential Information]] \| [[Use and Disclosure of Protected Health Information]] \| [[Notice of Privacy Practices]] \| [[Access to Designated Record Set]] \| [[Accounting of PHI Disclosures]] \| [[Patient/Consumer Complaints]] \| [[Vendors]] \| [[Fax Transmissions]] \| [[Psychotherapy Notes]] \| [[Facility Security]] \| [[Conditions of Treatment Form]] \| [[Informed Consent for UNMC Media]] \| [[Transporting Protected Health Information]] \| [[Honest Broker]] \| [[Social Security Number]] \| [[Third Party Registry]] \| [[Information Security Awareness and Training]]
	<br /><br />		<br /><br />
	~~POLICY NO~~: '''6066'''<br />		Policy No.: '''6066''<br />
	~~EFFECTIVE DATE~~: '''03/17/03'''<br />		Effective Date: '''03/17/03'''<br />
			Revised Date: <br />
			Revised Date: <br /><br />
	<big>'''Psychotherapy Notes Policy'''</big><br />		<big>'''Psychotherapy Notes Policy'''</big><br />

	NOTE: These guidelines are provided to assist UNMC workforce, including those in the patient treatment areas of the Munroe-Meyer Institute, the College of Medicine Optical Shop, the Lions Eye Bank and the College of Dentistry, as applicable, comply with HIPAA regulations. Those departments and clinics which fall under the jurisdiction of The Nebraska Medical Center and/or University Medical Associates should consult the policies and procedures of those entities for authoritative guidance.<br />

	=== Basis for Policy ===		=== Basis for Policy ===
	~~<br />~~		It is the policy of University of Nebraska Medical Center (UNMC) to protect confidentiality and privacy through appropriate use of information gathered in the course of employment or other affiliation with UNMC or entrusted to UNMC for academic, research, patient care, or administrative purposes.

	It is the policy of University of Nebraska Medical Center (UNMC) to protect confidentiality and privacy through appropriate use of information gathered in the course of employment or other affiliation with UNMC or entrusted to UNMC for academic, research, patient care, or administrative purposes. ~~<br />~~

	=== Policy ===		=== Policy ===
	~~<br />~~		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, 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, Executive Memorandum No. 27, and UNMC Policy No. 6057, Use and Disclosure of Protected Health Information.~~<br />~~

	=== Definitions ===		=== Definitions ===
	~~<br />~~

	'''Privacy''' is defined as the right of individuals to keep information about themselves from being disclosed.		'''Privacy''' is defined as the right of individuals to keep information about themselves from being disclosed.
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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 Deb Bishop,~~ Privacy Officer~~, or see Psychotherapy Notes Procedures.~~		===Additional Information===
			*Contact [mailto:dbishop@unmc.edu Privacy Officer]
	Psychotherapy Notes Procedures		*See Psychotherapy Notes Procedures

	~~This is a new UNMC Policy.<br />~~

	This page ~~updated on Monday, February 16, 2004,~~ by dkp.		This page maintained by [mailto:dpanowic@unmc.edu dkp]

Afaylor: add Faculty tab

2019-08-02T17:56:54Z

add Faculty tab

← Older revision		Revision as of 12:56, August 2, 2019
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	<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"		<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
	width="20">[[Intellectual Property]]</td>		width="20">[[Intellectual Property]]</td>
			<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
			<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
			width="20">[[Faculty]]</td>
	</tr>		</tr>
	</table>		</table>

Afaylor at 19:01, September 19, 2016

2016-09-19T19:01:57Z

← Older revision		Revision as of 14:01, September 19, 2016
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	</table>		</table>
	<br />		<br />
	[[Identification Card]] \| [[Secure Area Card Access]] \| [[Privacy/Confidentiality]] \| [[Computer Use/Electronic Information]] \| [[Confidential Information]] \| [[Protected Health Information ~~(PHI)~~]] \| [[Notice of Privacy Practices]] \| [[Access to Designated Record Set]] \| [[Accounting of PHI Disclosures]] \| [[Patient/Consumer Complaints]] \| [[Vendors]] \| [[Fax Transmissions]] \| [[Psychotherapy Notes]] \| [[Facility Security]] \| [[Conditions of Treatment Form]] \| [[Informed Consent for UNMC Media]] \| [[Transporting Protected Health Information]]		[[Identification Card]] \| [[Secure Area Card Access]] \| [[Privacy/Confidentiality]] \| [[Computer Use/Electronic Information]] \| [[Retention and Destruction/Disposal of Private and Confidential Information]] \| [[Use and Disclosure of Protected Health Information]] \| [[Notice of Privacy Practices]] \| [[Access to Designated Record Set]] \| [[Accounting of PHI Disclosures]] \| [[Patient/Consumer Complaints]] \| [[Vendors]] \| [[Fax Transmissions]] \| [[Psychotherapy Notes]] \| [[Facility Security]] \| [[Conditions of Treatment Form]] \| [[Informed Consent for UNMC Media]] \| [[Transporting Protected Health Information]] \| [[Honest Broker]] \| [[Social Security Number]] \| [[Third Party Registry]] \| [[Information Security Awareness and Training]]
	<br /><br />		<br /><br />
	POLICY NO: '''6066'''<br />		POLICY NO: '''6066'''<br />

Afaylor: /* Definitions */

2016-07-28T18:55:03Z

Definitions

← Older revision		Revision as of 13:55, July 28, 2016
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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 ~~Sheila Wrobel~~, Privacy Officer, or see Psychotherapy Notes Procedures.		For more information, contact Deb Bishop, Privacy Officer, or see Psychotherapy Notes Procedures.

	Psychotherapy Notes Procedures		Psychotherapy Notes Procedures

Afaylor: /* Policy */

2013-12-31T17:31:48Z

Policy

← Older revision		Revision as of 12:31, December 31, 2013
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	<br />		<br />

	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, Executive Memorandum No. 27, ~~andUNMC~~ Policy No. 6057, Use and Disclosure of Protected Health Information.<br />		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, Executive Memorandum No. 27, and UNMC Policy No. 6057, Use and Disclosure of Protected Health Information.<br />

	=== Definitions ===		=== Definitions ===