Psychotherapy notes aid mental health treatment by providing a comprehensive record of a client's progress, diagnosis, and treatment plans. With therapy notes containing highly sensitive information, mental health professionals must ensure that they are stored and handled in a HIPAA compliant way.
HIPAA and its relevance to therapy notes
HIPAA sets standards for the privacy and security of PHI across various healthcare settings. Therapy notes, as part of a client's mental health records, fall under the definition of PHI, making compliance with HIPAA regulations essential.
Therapy notes as protected health information
Therapy notes encompass the detailed records that mental health professionals maintain during their clients' treatment. They contain sensitive information about a client's mental health condition, therapeutic interventions, progress, and other pertinent details. Given the nature of the information they contain, therapy notes are considered PHI under HIPAA regulations.
Compliance requirements for therapy notes
Obtaining patient consent
Psychotherapy notes are treated differently from other mental health information because they are the therapist's personal notes that typically are not required or useful for treatment, payment, or health care operations purposes other than by the mental health professional who created the notes.
Therefore, the Privacy Rule requires a covered entity to obtain a patient's authorization before disclosure of psychotherapy notes for any reason, including disclosure for treatment purposes to another healthcare provider.
Security safeguards
Covered entities must implement appropriate administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of psychotherapy notes. This includes access controls, encryption, secure storage, and regular data backups.
Minimum necessary rule
Mental health professionals must limit the use, disclosure, and request of psychotherapy notes to the minimum detail required to accomplish the intended purpose. Only authorized individuals who need access to the notes should be permitted to view or use them.
Retention and disposal
HIPAA compliant policies and procedures must be established for the retention and proper disposal of psychotherapy notes. This includes determining the appropriate length of time to retain the notes and ensuring their secure destruction when they are no longer needed.
Breach notification
Covered entities must comply with the HIPAA Breach Notification Rule in the event of a breach of unsecured psychotherapy notes. If there is a risk of compromise to the confidentiality or integrity of the notes, affected individuals, the U.S. Department of Health and Human Services (HHS) must be notified.
Business associate agreements
A business associate agreement must be in place if a covered entity engages a business associate to perform services involving psychotherapy notes (e.g., electronic health record providers). This agreement outlines the business associate's responsibilities to protect the confidentiality of the notes and comply with HIPAA requirements.
Patient rights
Patients have specific rights regarding their treatment. This includes the right to request access, amendment, and an accounting of disclosures of their therapy notes. Covered entities must have processes in place to handle patient requests and provide the necessary information in a timely manner. When it comes to therapy notes, the patient does not have the right to see the full notes of the therapist. These notes are the private thoughts of the therapist and may not need to be shared in full. Treatment details like medications and appointment times can be requested by the patient.
The Dept. of Health and Human Services states, "Psychotherapy notes are treated differently from other mental health information both because they contain particularly sensitive information and because they are the personal notes of the therapist that typically are not required or useful for treatment, payment, or health care operations purposes, other than by the mental health professional who created the notes."
Additional considerations
- While HIPAA sets the minimum standards for protecting therapy notes, mental health professionals should also consider state and local laws that may provide additional protections.
- Careful consideration should be given to selecting secure EHR systems, secure email communication platforms, and encryption methods to protect therapy notes from unauthorized access.
- Ethical considerations extend beyond HIPAA compliance. Mental health professionals should adhere to their professional codes of ethics, which often require the highest standard of confidentiality and privacy for therapy notes.
Related: Psychotherapy notes and HIPAA
Ensuring HIPAA compliance for therapy notes is paramount in safeguarding patient privacy and maintaining the trust of clients seeking mental health treatment. Mental health professionals must understand the requirements of HIPAA, develop and implement appropriate safeguards, and regularly review and update their practices.
Liyanda Tembani
