There is a great deal of confusion around whether Psychotherapy notes can be withheld from patients. Under the Health Insurance Portability and Accountability Act (HIPAA), because of the sensitive nature of the information they contain, psychotherapy notes in most cases do not have to be released. 45 C.F.R. § 164.524.
Psychotherapy notes are defined as notes recorded by a mental health professional documenting or analyzing the content of a private counseling session. These are usually kept separate from the rest of the individual’s medical records because psychotherapy notes often contain the therapist’s impressions and details about the session. Psychotherapy notes are considered inappropriate for the medical record. They are usually intended to help the provider recall the session and assist with their treatment plan for the patient.
In addition, a provider must decide whether access to psychotherapy notes is reasonably likely to endanger the life or physical safety of the patient or another person. Therapists understandably often err on the side of caution when determining whether release of the notes is appropriate.
State laws are often even more restrictive than HIPAA and often require the patient to sign an actual authorization allowing psychotherapy notes to be released to another healthcare provider. These records do not fall under the exception for treatment payment or health operations as defined under HIPAA.
However, psychotherapy notes are not entirely shielded from disclosure. They can be disclosed in judicial proceedings if they are otherwise discoverable and the patient provides authorization for their release. Furthermore, psychotherapy notes can be disclosed without patient authorization under specific circumstances, such as for the health care provider’s own training programs, to defend against accusations of wrongful conduct, or when required by law.
If you are a provider being asked to disclose psychotherapy notes, you should consult an attorney to assist you in navigating the relevant statutes. Our attorneys at Revolution Law stand ready to help.
Revolution Law Group is located in Greensboro, NC, and serves individuals and small businesses throughout the Triad and surrounding areas. To contact us please visit Revolution.law or call 336-333-7907.
The information included here is for informational purposes only, is not exhaustive of all considerations when creating documents, is not intended to be legal advice, and should not be relied upon for that purpose. We strongly recommend you consult with an attorney and do not attempt to create your own documents.