Psychotherapy notes are considered protected health information (PHI) under HIPAA.
This means that psychotherapists, counselors, and other mental health professionals must ensure that these notes are properly secured to protect their patients’ privacy.
Keep reading to learn more about how HIPAA applies to psychotherapy notes.
The HIPAA Privacy Rule defines psychotherapy notes as “notes recorded by a mental health professional documenting the contents of conversation during a counseling session that are separated from the rest of the individual’s medical record.”
Psychotherapy notes consist of a therapist’s observations, hypotheses, thoughts, and feelings. They do not include information such as progress updates, symptoms, treatment plans, session start and stop times, or results of clinical tests.
The overall goal of psychotherapy notes is to help psychotherapists gain a deeper understanding of a patient’s particular situation.
Psychotherapy notes receive special protections under the Privacy Rule. This is because they are likely to contain highly sensitive content. In addition, these private notes are only relevant to the provider. They are not typically needed for treatments, payments, or other operations.
Therefore, patients are not permitted to access psychotherapy notes. While they have the opportunity to request access, their provider is not required to oblige.
Furthermore, covered entities must receive a patient’s authorization before disclosing these notes at any time. Certain exceptions exist when other laws come into play, such as mandatory reporting of abuse and other situations that involve serious threats or harm.
Whether psychotherapy notes are stored digitally or written by hand, it’s important for mental health professionals to keep them just as protected as patients’ medical records. This is the smartest way for providers to stay HIPAA compliant and avoid unintentional exposures of PHI.
In order to comply with HIPAA guidelines, psychotherapy notes need to be stored securely in an area that is only accessible by authorized individuals.
For instance, physical notes may be kept in a locked filing cabinet. Digital therapy notes are also especially susceptible to cyberattacks. Therefore, providers should make sure they are implementing two-factor authentication, using strong passwords, and keeping software up-to-date.
The safest way to store psychotherapy notes electronically is to use secure therapy notes software or a password-protected EHR system that meets HIPAA standards.
More best practices include leaving out identifying information and thoroughly destroying notes once they are no longer needed. This can be accomplished by shredding paper notes or wiping data from digital platforms.
Related: 9 ways to securely store and share patient therapy notes
In addition, there are instances where a psychotherapist may need to communicate with another provider about a patient. Transmitting therapy notes should also be done with privacy top-of-mind. Avoid discussing patient matters on the phone and always use HIPAA compliant email.
Finally, ensure that your staff is adequately trained in HIPAA compliance and knowledgeable about the procedures for storing therapy notes. Explain why patient privacy is important, offer guidance on secure storage strategies, and educate them on the potential risks of violating these requirements.
Psychotherapy notes are considered PHI, which means mental health professionals must take proactive steps to safeguard this information.
Secure physical and electronic storage policies are key to complying with HIPAA requirements and protecting patients’ sensitive data.
Related: How to send HIPAA compliant emails