Psychotherapy Notes: Difference between revisions

POLICY NO: '''6066'''<br />

EFFECTIVE DATE: '''03/17/03'''<br />

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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 />  

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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 />

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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)

For more information, contact Sheila Wrobel, Privacy Officer, or see Psychotherapy Notes Procedures.