TITLE:

CONFIDENTIALITY OF PSYCHOTHERAPY AND PERSONAL NOTES

POLICY:
Psychotherapy and personal notes are considered the property of the health care provider who created them, and will not be released or disclosed to patients.

PURPOSE
Psychotherapy and personal notes are specially protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and by state law. The purpose of this policy is to define "psychotherapy notes" and "personal notes" and to describe how and why they are separately protected.

PROCEDURES:

1. Definitions.
1. "Psychotherapy notes" are defined as:
1. notes recorded in any medium (e.g., on paper, electronically, etc.) by a mental health care provider who is documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session, and



2. that are kept separate from the rest of the patient's medical record.



3. The term "psychotherapy notes" excludes:
1. medication prescription and monitoring;
2. counseling session start and stop times;
3. the modalities and frequencies of treatment furnished;
4. results of clinical tests; and
5. any summary of the patient's diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date.


2. "Personal notes" means:
1. the practitioner's speculations, impressions (other than tentative or actual diagnosis), observations, and reminders, if



2. they are maintained by a practitioner.


3. A "mental health care provider" is a healthcare provider who is a mental health professional.



4. A "practitioner" is a licensed or registered physician, dentist, podiatrist, chiropractor, nurse, midwife, physician assistant or specialist assistant, physical therapist, or optometrist.


2. Non-disclosure of psychotherapy and/or personal notes.
1. Psychotherapy and/or personal notes should not be documented or included in the patient's medical record.



2. Only if psychotherapy and/or personal notes are documented or included in the patient's medical record, will they be:
1. considered part of the patient's medical record; and



2. disclosed in accordance with Columbia University Medical Center policies and procedures; and



3. disclosed to the patient who requests access to or a copy of the patient's medical record.


3. Questions. Questions about disclosing psychotherapy and/or personal notes should be directed to the employee's supervisor or the HIPAA Privacy Officer.

RESPONSIBILITY:         Departments, HIPAA Privacy Officer