Tag Archives: HIPAA

Progress Notes and Psychotherapy Notes

How can I protect the notes I take during supervision and consultation from being seen by a client who requests her record?  I find the notes valuable in planning for sessions and for tracking my own countertransference, but I don’t want clients to be able to see my notes.  

Your question refers to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) which make all health records accessible to clients upon request.  There is an exception, however, that is important to know in creating and maintaining documentation for psychotherapy.  Chapter 10 of my book covers issues related to HIPAA and other issues to consider in clinical documentation.  

HIPAA defines progress notes as part of the treatment record which must be provided to the client and psychotherapy notes as the property of the clinician and kept outside of the treatment record.  I’ll define each of these terms more specifically and describe the practices that make it clear whether you are creating a progress note or a psychotherapy note.

Progress notes are part of the client record and are used to document the service you provided. Generally they include information about the date, time, location, and length of the session; who attended; the client’s mental health status in terms of symptoms and functioning; your interventions and the client’s response; assessment of any risk or danger; progress toward treatment goals; and plan for continued treatment or referrals.  Progress notes are written in objective, professional language and are relatively concise. These notes may be requested by a third party funder to support a billing claim or as part of a periodic audit.  If the client requests her/his record, you are required to provide copies of the progress notes along with other clinical documentation such as assessments and treatment plans.  

Psychotherapy notes, as defined by HIPAA, contain material that is clinically relevant to the clinician but not required to document the service provided.  Examples of material that is appropriate for a psychotherapy note rather than a progress note are impressions or hypotheses, details of the client’s history or therapeutic interactions that are meaningful but not necessary for a progress note, descriptions of your personal countertransference responses, and notes from supervision or consultation.  

Based on these definitions, your notes from supervision and consultation are psychotherapy notes and are not part of the client’s record.  However, you need to use care in how you keep the psychotherapy notes in order to be clear that they are your property and kept for clinical purposes only.  I recommend keeping your psychotherapy notes in a separate folder rather than keeping them in the client’s chart.  This makes it less likely that there will be any misunderstanding or confusion if the client does request the record or gives permission for you to release the record to a third party.  If you work in an agency, you may not receive the request, and another staff member may not be able to distinguish between progress notes and psychotherapy notes if they are kept in the same chart.  If you receive the request yourself, it may be difficult to separate them without the time consuming step of reading each individual note.

There are no requirements for keeping psychotherapy notes for a specified period of time, in contrast to legal and ethical requirements for keeping client records for seven years or more after the end of treatment.  For this reason, you may wish to destroy your psychotherapy notes once they are no longer clinically relevant.  You may also wish to keep the psychotherapy notes free of any identifying information that could fall under the HIPAA definition of Protected Health Information (PHI).  If you use initials only or a number code that is known only to you, it is more clear that the psychotherapy notes are not part of the client record.   

I hope this clarifies the question of what notes must be disclosed to the client and what can be kept for your own use.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Client Requests for Records

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therapyI had a session today in which a client asked to see the notes I have taken that are part of her chart.  I told her I’d have to talk to my supervisor because I’ve never had a client ask for this before.  What choices do I have in deciding whether to give her the notes or not?

This issue was addressed by HIPAA, which created a national standard for client’s access to all medical records including records of psychotherapy.  Under HIPAA, the record belongs to the client and s/he has a right to request and receive a copy.  Exceptions are only made for instances where viewing the record would cause serious harm to the client and, in the case of child records requested by parents, harm to the psychotherapy relationship.  Most behavioral health agencies ask clients to make a written request and then provide a copy of the records within 1-3 weeks.

While HIPAA addresses client access to records from an administrative perspective, it doesn’t address the clinical issues that are often present when a client requests a copy of the current treatment record.  Your supervisor can be helpful in talking through the meaning and motivation for your client bringing this up with you.  Some factors to consider are the client’s previous experiences of secrecy and betrayal, issues of control and helplessness, interpersonal suspiciousness, and involvement in a legal case or application for disability.  Your client is more likely to tell you about the reasons she wants to see your notes if you make it clear first that you plan to honor her request.  In your next session, you can say “You told me last week you wanted to see the notes I have written for your chart.  I have the written request here for you to fill out, and I also am interested in what led you to ask for the notes.”  You can explore this further, if the client is willing to do so, by asking what she expects to see in the notes and how she feels about looking at them.

Most clinicians, especially those in field placement or practicum training, feel anxiety when a client requests the record.  You may anticipate, correctly or incorrectly, that the client will be upset or offended by things you have written in progress notes or the assessment.  Your assessment may include a diagnosis and case formulation that you haven’t explicitly shared with the client.  Your notes may accurately reflect some of the client’s obstacles to improvement and progress.  It is usually helpful to look at the record and to have your supervisor review it to identify anything that could be problematic.  Whether or not you anticipate a negative reaction from the client, it is usually wise to say “There may be portions of this record that spark questions or upsetting feelings for you.  I’d like to talk with you about anything that comes up after you’ve read it.”  Then you should follow up with a discussion in the following session about what it was like for her to look at her record.  If she has questions or was distressed by anything you wrote, I recommend being straightforward in your explanation.  If you regret anything you wrote, you can acknowledge that you wish you had used different wording or had described the situation differently.  In addition to negative feelings, she may feel pleased with her self-assertion and have an increased sense of empowerment when you respond to her request in a respectful, professional manner.

I hope you find this helpful in handling client requests for records.  Please email me with comments, questions or suggestions for future blog topics.