Interested in learning more about the differences between psychotherapy notes and progress notes? Click here to subscribe. Psychotherapy notes absolutely must be separated and distinguishable from the rest of the individualвЂ™s medical record in order to be protected against disclosure policies. This optional type of documentation tends to be more sensitive in nature and may include hypotheses, transference, and other theoretical applications. As you might remember from graduate school, psychotherapy notes are taken by mental health professionals to document or analyze the content of a psychotherapy session and may contain information that is inappropriate for a medical record. Hopefully, you noticed that a very important type of therapy or counseling note is not included in the mandatory disclosure list of HIPAA or Open Notes - psychotherapy notes. What Are the Eight Types of Clinical Notes to be Released in Open Note?Д«efore we break down how the Open Notes policy impacts mental health clinicians in private practice, letвЂ™s clarify the eight types of clinical notes that must be shared:ДЄre Psychotherapy Notes Part of Open Note? Original sources are linked, as well as a list of additional Open Note resources at the end of the page. Before continuing, I must clarify that I am not an expert on Open Note, and the following is a summary of the information I have been able to find thus far. This applies to both in-person services and virtual counseling or online therapy. As part of the 21st Century Cures Act passed in 1996, healthcare providers (yes, this includes us therapists, counselors and psychologists) will be required to give patients access to all health information in their electronic medical records without charge beginning April 5th, 2021. IвЂ™d like to think that I stay on top of psychotherapy news, but the Open Note policy change caught me off guard. What is Open Note and How Will It Impact Mental Health Professionals? Consult with your organizationвЂ™s Health Information Management, compliance, legal, finance, and public affairs teams to find out how it applies to you.

State laws around data release may not be superseded by the 21st Century Cures Act. This article is not official technical or legal advice.

Free mental health note taking software