Psychotherapy Notes

POLICY NO : 6066

EFFECTIVE DATE: 03/17/03

Psychotherapy Notes Policy

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.

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.

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, andUNMC Policy No. 6057, Use and Disclosure of Protected Health Information.

Definitions

Privacy is defined as the right of individuals to keep information about themselves from being disclosed.

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.

Psychotherapy Notes Procedures

This is a new UNMC Policy.

This page updated on Monday, February 16, 2004, by dkp.