University of Nebraska Medical Center

Psychotherapy Notes

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Policy No.: 6066
Effective Date: 03/17/03
Revised Date: 09/22/22
Review Date: 09/22/22

Psychotherapy Notes 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 Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements.

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, University of Nebraska Executive Memorandum No. 27 and UNMC Policy No. 6057, Use and Disclosure of Protected Health Information.

Procedures

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.

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

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).

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

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).

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

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