Avoiding Liability Bulletin – June 2005

… Under federal regulations implementing HIPAA, a patient has certain rights with respect to inspecting and copying their health records when they make a specific request to do so in writing. Those regulations also make clear, among other things, that the provider does not have to give the patient a copy of the “psychotherapy notes,” which are defined as the notes 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 and that are separated from the rest of the individual’s medical (includes mental health) record.

Be careful – under the HIPAA regulations you must distinguish between “psychotherapy notes” and “psychotherapy records” – they are not the same. “Psychotherapy records” would include, for instance, any summary of the diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date. It would also include the results of clinical tests, the modalities and frequencies of treatment furnished, and counseling session start and stop times. Remember, HIPAA applies to those who are “covered providers.”

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Richard Leslie

Richard S. Leslie is an attorney and acknowledged expert on the interrelationship between law and the practice of marriage and family therapy and psychotherapy. Most recently, he was a consultant to the American Association for Marriage and Family Therapy (AAMFT) and has written articles regarding legal and ethical issues for their Family Therapy Magazine. Prior to his work with AAMFT, Richard was Legal Counsel to the California Association of Marriage and Family Therapists (CAMFT) for approximately twenty-two years. While there, he also served as their director of Government Relations and tirelessly advocated for due process and fairness for licensees and applicants.

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