Corporate Compliance

HIPAA Q&A: Psychotherapy notes and privacy

Compliance Monitor, March 21, 2012

Q. I am confused about the privacy of psychotherapy notes. Will you explain?

A. You are not alone. According to HIPAA, psychotherapy notes are protected from release. However, the key thing to remember is that, to be protected under HIPAA, psychotherapy notes must be kept separate from the medical record and not used to substantiate billing. Providers would, therefore, have to keep two sets of notes: one set for the chart that would be subject to release and would substantiate billing, and another set for private use. Because most providers don’t want to keep two sets of notes, true psychotherapy notes are rarely used.

Note that many states have laws with special protections for mental health information; these laws would apply if they are more stringent than HIPAA. Remember, too, that there are federal laws protecting information produced by substance abuse treatment providers and facilities, and these might also apply.

Editor's note: Chris Simons, RHIA, director of health information and privacy officer at Cheshire Medical Center/Dartmouth-Hitchcock in Keene, NH, provided the answer to this question in the March issue of Medical Records Briefing.

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