University Information Security and Privacy Office

Psychotherapy Notes

PSYCHOTHERAPY NOTES 

A patient generally has the right to a copy of their health information. One exception is psychotherapy notes. The notes have special protections because they may contain particularly sensitive information - and they are the notes of the treating therapist intended to help him or her recall the therapy (generally not of use to others). Psychotherapy notes are maintained by mental health professional separately from the record and are "notes recorded in any medium by a mental health professional documenting or analyzing the contents of conversation during a private counseling session." These notes, which capture the psychologist's impressions about the patient and can contain information that is inappropriate for a medical record, are similar to what psychologists have historically referred to as "process notes."

Under HIPAA, a psychotherapy note is:

  1. Recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session, AND,
  2. Maintained separate from the medical record, AND
  3. That exclude:
    1. Medication prescription and monitoring
    2. Counseling session start and stop times
    3. The modalities and frequencies of treatment furnished
    4. Results of clinical tests
    5. Any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

University Health Care must obtain an individual's authorization to use or disclose psychotherapy notes with the following exceptions:

  • i originated by University Health Care, we may use them for treatment purposes.
  • for internal training purposes;
  • to defend UUHSC in legal proceedings brought by the individual;
  • for HHS to investigate;
  • to avert a serious and imminent threat to public health or safety;
  • to a health oversight agency for lawful oversight of the originator of the psychotherapy notes; OR
  • for the lawful activities of a coroner or medical examiner or as required by law.

Can psychotherapy notes be disclosed directly to the patient?
Psychotherapy notes can only be released to the patient if the provider agrees (make sure to use the "Authorization for Use or Disclosure of Psychotherapy Notes").

Can psychotherapy notes be disclosed to another provider?
Yes, the patient can authorize the disclosure of psychotherapy notes to anyone BUT THEMSELVES (unless the provider agrees). The patient must fill out the Authorization for Use or Disclosure of Psychotherapy Notes.

Psychotherapy notes released pursuant to subpoena AND authorization:
If UUHSC receives a subpoena for records that includes a request for psychotherapy notes, and if the subpoena comes with an authorization signed by the patient, we must provide the psychotherapy notes.

Bottom Line

With limited exceptions, we do not release psychotherapy notes unless we have written patient authorization.