Separating psychotherapy notes from the rest of the medical record
Compliance Monitor, February 10, 2006
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Q: Why should we separate psychotherapy notes from the rest of the medical record?
However, summary information that does not include psychotherapy notes is always placed in the patient's medical record. Summary information includes
- the patient's current state and symptoms
- a summary of the theme of the psychotherapy session
- diagnoses
- medications prescribed and their side effects
- any other information necessary for treatment or payment
For more information see Section 164.501 Definitions: Psychotherapy Notes.
Editor's note: Attorneys from Bricker & Eckler, LLP, answered this question. This is not legal advice. Consult with your attorney for legal matters.
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