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.