Section 37: Use and Disclosure of Psychotherapy Notes
Psychotherapy notes: Notes (i.e. process notes) that capture the therapist’s impressions about the patient containing details of the conversation considered to be inappropriate for the medical record, and are used by the provider for future sessions. Psychotherapy notes can also be recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes are kept separate from the rest of the individual’s medical record.
UTD may not release psychotherapy notes, except in specific situations or as required by law. Psychotherapy notes (i.e., process notes) shall be maintained separately from the medical record. Summary information (i.e., progress notes) such as current state of the patient, symptoms, summary of the theme of the psychotherapy session, diagnoses, medications, side effects, and other information needed for treatment or payment shall be placed in the medical record.
Authorization for the disclosure of psychotherapy notes is not required in the following circumstances:
- For use by the originator for treatment;
- For use in educational programs including graduate training programs where students and trainees learn to practice counseling;
- To defend a legal action brought by the patient;
- For purposes of the Department of Health and Human Services in determining compliance with the privacy rule;
- As otherwise required by law;
- By a health oversight agency for a lawful purpose related to oversight of a psychotherapist;
- To a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law; or,
- To a law enforcement in instances of permissible disclosure related to a serious or imminent threat to the health or safety of a person or the public.