Psychotherapy Notes

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The privacy rule defines psychotherapy notes as per HIPAA "Notes recorded in any medium by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are 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." This is usually applicable in inpatient setting but not clear about the [1]

References

  1. , Nicholson Ruby. "The Dilemma of Psychotherapy Notes and HIPAA." Journal of AHIMA 73, no.2 (2002): 38-39.