Not all medical record types are the same, as certain types of records require more sensitive handling due to their greater privacy and confidentiality restrictions, including Psychotherapy notes. These notes are often confused with mental or behavioral health records, which are separate and distinct. It’s important to understand if psychotherapy notes reside in your electronic health record (EHR) system, and then process those records in accordance with HIPAA and other privacy standards.

What are Psychotherapy notes?

Psychotherapy notes are defined as notes recorded by a healthcare provider who is a mental health professional documenting or analyzing the contents of conversation during a private, group, joint, or family counseling session. Essentially, these are the “couch notes” of the provider, containing unfiltered, stream of consciousness thoughts to be analyzed and synthesized later. By definition, these notes must be separate from the rest of the individual’s medical record to be considered psychotherapy notes.  If the psychotherapy notes are not given a distinct designation and separated from the rest of the designated record set, the notes do not meet the definition of psychotherapy notes.  Mental health professionals must define the distinction of psychotherapy notes and partition them in the EHR to provide the protections expected of these notes.  By best practice, these notes are generally excluded from release of information, unless providers specifically choose to release them.

What Are Mental Health Records?

Mental health medical records are more encompassing than psychotherapy notes.  Even though they may contain components that look like they could be psychotherapy notes, they are not one in the same.  Mental health records can contain medication prescriptions, counseling session start and stop times, results of clinical tests, diagnosis, symptoms, prognosis and other health information, which are part of the patient’s general health record. Often psychotherapy notes are utilized in creating mental health records, but mental health notes remain separate and distinct.  Psychotherapy notes are excluded from a patient’s mental health medical records.  Mental health records are part of the designated record set, and unlike psychotherapy notes, are required to be released if a Right to Access request is received.

How Should You Handle these types of Records?

As psychotherapy and mental health notes differ by definition, they also are handled differently in the release of information process.  As a best practice, psychotherapy notes are not typically released unless approved by the provider.  As mental health records are part of the designated record set, they are expected to be released for compliant authorization and Right to Access requests, unless they meet criteria the practice establishes for exclusion.

Let Go of the Complicated REquests

Confused by the difference in psychotherapy versus mental health notes, and how to process what? ScanSTAT is here to help.  We’re happy to handle both the routine requests, and the more complicated, allowing you to focus on taking care of your patients instead of paperwork.  If you’d like to learn more about how we can alleviate these requests from your daily workload, reach out to us to schedule a demo today.

This FAQ is for informational purposes only and does not constitute legal advice. Seek your own legal counsel to ensure compliance with federal and state law.