HIPAA GENERAL OPERATING POLICY #8
PSYCHOTHERAPY NOTES
I. Definition
"Psychotherapy Notes" means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the content of conversation during a private counseling session or a group, joint or family counseling session and that are separated from the rest of the individual’s medical record. "Psychotherapy Notes" excludes 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.
II. Limitation on Uses and Disclosures
Notwithstanding any other provision of the Privacy Regulations, except for the transition provisions, a HCC must obtain an authorization for any use or disclosure of psychotherapy notes, except for:
a. Use by the originator of the psychotherapy notes for treatment;
b. Use or disclosure by the HCC for its own training programs in which students, trainees or practitioners in mental health learn under supervision to practice or improve their skills in counseling;
c. Use or disclosure by the HCC to defend itself in a legal action or other proceeding brought by the individual; or
d. A use or disclosure that is required by the DHHS, required by law, required by court order with respect to the oversight of the originator of the psychotherapy notes, is permitted to a coroner or medical examiner to identify a deceased person or cause of death, or as is necessary to avert a serious and imminent threat to the health or safety of a person or the public.