Part 2, Chapter 7: Manual Exhibit 2-7-N
Policy and Procedure for Maintenance, Use,
and Disclosure of
- PURPOSE. To publish the Indian Health Service (IHS) policy and procedure on the maintenance, use, and disclosure of psychotherapy notes.
- AUTHORITY. 45 Code of Federal Regulations 164.508(a)(2)
- POLICY. All psychotherapy notes recorded on any medium (i.e., paper, electronic), by a mental health professional, such as, a psychologist or psychiatrist must be kept by the author and filed separately from the rest of the patient’s medical record to maintain a higher standard of protection.
- DEFINITION. Psychotherapy notes means process notes (not progress 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 for his or her use only, and are separated from the rest of the patient’s medical record.
- PROCEDURES. Psychotherapy notes may be used or disclosed following the procedures below:
- Disclosure Authorization. When disclosing psychotherapy notes to the patient or to another individual, the IHS 810, “Authorization for Use and Disclosure of Health Information,” must be dated, signed by the patient or legal guardian (if the patient is a minor or incompetent), or the patient’s personal representative, and the box for “Psychotherapy Notes” must be checked. The authorization should not be used in conjunction with other disclosures or uses.
- Authorization Not Required. An authorization is not needed to use or disclose psychotherapy notes for:
- Providing treatment, payment, or health care operations:
- use or disclosure by the originator of the notes for treatment;
- use or disclosure for mental health training programs under supervision within the IHS facility; or
- use or disclosure by the IHS in a legal action or other proceedings brought by the patient, in consultation with the Office of General Counsel;
- use or disclosure that is required by law, authorized disclosure to a health oversight authority with respect to the oversight of the originator of the psychotherapy notes, or the use or disclosure to report a serious and imminent threat to the health and safety of the patient or a third party;
- use or disclosure required by the Secretary, Department of Health and Human Services, to investigate IHS facility compliance with the Privacy Act and Health Insurance Portability and Accountability Act Privacy Rule; or
- use or disclosures to medical examiners or coroners about deceased patients to determine identity, cause of death, or to perform other duties as authorized by law.
- Psychotherapy notes do not include:
- medication prescription and monitoring;
- counseling session start and stop times;
- the modalities and frequencies of treatment furnished;
- results of clinical tests; and
- any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
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