Psychotherapy Notes: Difference between revisions

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POLICY NO : 6066<br />
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EFFECTIVE DATE: 03/17/03<br />
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[[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]]
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POLICY NO: '''6066'''<br />
EFFECTIVE DATE: '''03/17/03'''<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 />
   
   
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 />
<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. <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. <br />  
 
 


=== Policy ===
=== Policy ===
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<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, andUNMC Policy No. 6057, Use and Disclosure of Protected Health Information.<br />


=== Definitions ===
=== Definitions ===
<br />
<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.
'''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''' 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
Psychotherapy Notes Procedures


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


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