Full Answer
Are mental health records considered medical records?
These pieces of information are considered mental health records, and thus part of the patient’s general medical record. As patients move between different healthcare providers, it is critical that health information be appropriately documented and shared for proper continuity of care of the patient.
Who owns your mental health treatment records?
While mental health treatment records are owned by the practitioner (assuming a private practitioner/sole proprietorship), patients have certain rights with respect to accessing their treatment records.
What if a patient is denied access to their mental health records?
A patient who is denied access to their mental health records under situations (2) to (4), above, is entitled to have the denial reviewed by a licensed independent practitioner identified by the provider. ( Id. at § 164.524 (a) (4)).
What are a therapist’s rights to patients’ medical records?
As a therapist, you may occasionally have a patient request access to their clinical records. Patients have an array of rights with respect to their mental health records, but these rights differ under California and federal law.
What do mental health records include?
HHS outlines psychotherapy notes are not inclusive of medical prescriptions, session start and stop times, frequency of treatment, clinical tests, summaries of diagnosis, symptoms, prognosis, etc. These pieces of information are considered mental health records, and thus part of the patient's general medical record.
What are the three main types of health records?
There are three types of medical records commonly used by patients and doctors:Personal health record (PHR)Electronic medical record (EMR)Electronic health record (EHR)
What is defined as a medical record?
Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication.
Does HIPAA include mental health records?
HIPAA provides a personal representative of a patient with the same rights to access health information as the patient, including the right to request a complete medical record containing mental health information. The patient's right of access has some exceptions, which would also apply to a personal representative.
What are the five types of records?
Types of recordsCorrespondence records. Correspondence records may be created inside the office or may be received from outside the office. ... Accounting records. The records relating to financial transactions are known as financial records. ... Legal records. ... Personnel records. ... Progress records. ... Miscellaneous records.
What are the two types of records?
These generally fall into two categories: policy records and operational records.
What is considered a medical record under Hipaa?
Medical records and billing records about individuals maintained by or for a covered health care provider; Enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or.
What is an example of a medical record?
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc.
What are the two most common types of medical records?
Paper-based medical records and electronic medical records are the two most common types of medical records.
Is mental health treatment confidential?
Anything you talk about with your psychiatrist is confidential. You should feel that you can tell your psychiatrist anything. Sometimes your psychiatrist may need to share some of your private information with other health-care professionals so they can assist with your treatment.
What are two main differences between mental health records and general health records quizlet?
what are the two main differences between mental health records and general health records? added requirements for record content and more stringent privacy required. what is required of psychiatric facilities that receive Medicare funds?
What is excluded from protected health information?
The Privacy Rule excludes from protected health information employment records that a covered entity maintains in its capacity as an employer and education and certain other records subject to, or defined in, the Family Educational Rights and Privacy Act, 20 U.S.C. §1232g. De-Identified Health Information.
Why are mental health records not protected?
Records related to mental health do not receive these extra protections because they are considered part of the general record . Essentially, this distinction means thought and care should be put into how this information is stored and possibly shared, as most are not privy to the sensitive information contained in psychotherapy notes.
Why is it important to have medical information shared with patients?
As patients move between different healthcare providers , it is critical that health information be appropriately documented and shared for proper continuity of care of the patient. Diagnosis and medication information is imperative for any healthcare provider to properly and confidently provide care to a patient.
What is the HIPAA Privacy Rule?
HHS uses the HIPAA Privacy Rule to define psychotherapy notes “as notes recorded by a healthcare provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint or family counseling session and that are separate from the rest of the patient’s medical record.”
How to store psychotherapy notes?
Best practices state mental health records be stored within the patient’s general medical chart, while psychotherapy notes should be stored separately from the patient’s general medical record. If an organization wishes to store the psychotherapy notes within their electronic health record (EHR) system, then special naming and filing standards should be documented and communicated. Staff members should be trained on the differences between psychotherapy notes and mental health records. Mental health records should be coded as such and included in the patient’s general electronic record. The psychotherapy notes should then receive an individualized designation which communicates the relevant patient while not being added to that patient’s general medical record.
What is the difference between mental health and psychotherapy notes?
HHS states their reasoning as, “Psychotherapy notes are treated differently from other mental health information both because they contain particularly sensitive information and because they are the personal notes of the therapist that typically are not required or useful for treatment, payment or health care operations purposes other than by the mental health professional who created the notes.”
What is professional discretion?
Essentially, healthcare providers maintain professional discretion on when and what information should or should not be released. Circumstances pertaining to family access to psychotherapy notes, law enforcement inquiries, and third party requestors are especially dependent on this caveat to determine compliance.
Do you need to request a third party authorization for a psychotherapy note?
If a third party requestor is seeking to obtain medical records from the healthcare organization then the records custodian should follow their normal protocol in seeking the required authorization. If psychotherapy notes relating to the requested records are also present at the organization, an organization must seek separate patient authorization, which specifically states that psychotherapy notes may be included, before releasing the notes to the third party requestor. This is of paramount importance as the inappropriate release of psychotherapy notes would not only be noncompliant but it may have undesirable effects on the related patient.
How is information related to mental health treated under HIPAA?
How information related to mental health is treated under HIPAA; When information related to mental health may be shared with family and friends of an individual with mental illness, including parents of minors; and. The circumstances in which information related to mental health may be disclosed for health and safety purposes.
What is HIPAA for mental health?
HIPAA recognizes that some patients (including those with a mental illness or substance use disorder) may be unable to make their own health care decisions, including decisions related to health information privacy. HIPAA provides personal representatives of a patient with the same rights to request and obtain health information as the individual, ...
What is HIPAA law?
The HIPAA Rules are designed to protect the privacy of all of an individuals’ identifiable health information and to ensure that health information is available when needed for treatment and other appropriate purposes. Given the sensitive nature of mental health and substance use disorder treatment information, ...
Why do we need to share information about mental health?
At times, health care providers need to share mental and behavioral health information to enhance patient treatment and to ensure the health and safety of the patient or others.
What is the role of parents in mental health?
Parents, friends, and other caregivers of individuals with a mental health condition or substance use disorder play an important role in supporting the patient’s treatment, care coordination, and recovery.
Can a patient share their health information with family?
HHS Office for Civil Rights has released guidance on when and how healthcare providers can share a patient’s health information with his or her family members, friends, and legal personal representatives when that patient may be in crisis and incapacitated, such as during an opioid overdose.
Can a healthcare provider refuse to treat a patient as a personal representative?
HIPAA also allows a health care provider to determine, based on professional judgment, that treating someone as a patient’s personal representative for HIPAA purposes would endanger the patient, and to refuse to treat the person as a personal representative under those circumstances.
What is the purpose of HIPAA?
1. HIPAA was passed to establish national security and privacy standards in regard to health care information. HIPAA contains many complex provisions and requirements.
Who enforces HIPAA?
The Office for Civil Rights, the governmental body that enforces HIPAA rules, have taken enforcement actions, ranging from issuing a resolution agreement to civil monetary penalties, against covered entities for failure to follow HIPAA rules regarding patients' access to records. Resources.
What is PHI in medical?
4. There are certain circumstances where you may deny a patient's right to inspect or obtain PHI. In some instances, you must provide the patient with an opportunity to have your decision reviewed by another licensed practitioner.
What is legal department article?
Articles by Legal Department Staff. The Legal Department articles are not intended to serve as legal advice and are offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise.
What is PHI in healthcare?
PHI includes, but is not limited to, information created or received by a health care provider that relates to the past, present, or future physical or mental health or condition of an individual, including payment of services, that identifies the patient; or information that can be used to identify the patient.
What is a covered entity under HIPAA?
HIPAA applies only to covered entities and business associates. 2 The law defines a "covered entity" as: 1) a health plan; 2) a healthcare clearinghouse; and 3) a health care provider, who transmit health information in electronic form in connection with certain administrative and financial transactions. 3.
Is e-mailing a patient a covered entity?
Bear in mind that e-mailing your patients, storing electronic records, or providing therapy services electronically are not "covered transactions" under HIPAA. Accordingly, these practices alone will not render you a "covered entity.". Therefore, to determine if you are a covered entity and must comply with HIPAA laws, ...
Who owns mental health records?
While mental health treatment records are owned by the practitioner (assuming a private practitioner/sole proprietorship), patients have certain rights with respect to accessing their treatment records. These rights are typically specified by state statute, but for those who are “covered entities” under HIPAA these rights are found in ...
What are HIPAA rights?
These rights are typically specified by state statute, but for those who are “covered entities” under HIPAA these rights are found in the federal regulations known as the Privacy Rule. Patients or clients may gain access to their records by either obtaining a copy of the records or by inspecting the records. From the practitioner’s standpoint, ...
Can a mental health practitioner deny access to records?
Under specified circumstances, access to the records either may or must be denied. The grounds for a denial may vary when state law is compared to the Privacy Rule. In order to deny access in California, the practitioner must determine that there is a substantial risk of significant adverse or detrimental consequences to a patient in seeing or receiving a copy of the mental health records requested by the patient. The law then specifies several other actions that the practitioner must take, including what content must be entered into the records. For those who are covered entities under HIPAA, the standard for denial is worded differently (e.g., but not limited to, where access is reasonably likely to endanger the life or physical safety of the individual or another person). Some denials of access by the practitioner (under HIPAA) are not reviewable (e.g., denial of access to “psychotherapy notes”), while other denials are reviewable. When denying access under the Privacy Rule, the practitioner must, among other things, provide a timely, written denial that contains the basis for the denial and information regarding the review rights for the individual seeking access.
Can a patient consent to a summary?
Sometimes, after thoughtful discussion and reasoning, patients may consent to a summary.
Can a minor's parent inspect a minor's medical records?
With respect to parental access to a minor’s records, California law specifies that the representative of a minor “ shall not be entitled to inspect or obtain copies of the minor’s patient records” under two circumstances.
Can a summary of a medical record be provided in California?
Under HIPAA regulations (the Privacy Rule), a summary can only be provided if the patient agrees in advance to a summary and to the reasonable, cost-based fee imposed, if any, by the practitioner for preparation of the summary. For those governed by state law, more latitude may be given to the practitioner. In California, for example, a summary of the records may be provided in the discretion (hopefully, the sound discretion) of the practitioner. There are no findings that first have to be made and no conditions that first have to be met (California may be alone in this regard). When provision of a summary is permitted, whether in the sole discretion of the practitioner or under specified conditions, it is important to know whether there is specific content that must be contained in the summary and what that content is. In California, the relevant statute lists at least eight specific things that must be included in a summary of the records.
What does it mean when a court order requires a patient to disclose their medical records?
What this means is that a judge has determined that your clients records must be disclosed as part of a legal proceeding and that this disclosure is consistent with the law.
What are the two forms of legal requests for information?
Outside of patient authorizations for the release of their records, legal requests for information generally come in two forms: court orders and subpoenas. These are different entities and, consequently, the responses to them are different.
What if you get a subpoena with an authorization?
At that point in time they need to work with their attorneys to decide what is in their best interest legally but, without an authorization, the information cannot be provided.
What is the confusion in a patient file?
Many a psychologist has been confronted by the ever-present confusion that seems to take place when patient files are requested as part of a legal proceeding. This confusion frequently leads to a variety of questions that revolve around issues of whether these requests mandate disclosure, what records must be disclosed and whether ...
What happens if you receive a court order for records?
In a simple sense, if you receive a court order for records you must comply or risk sanctions by the court.
Can a subpoena be released without a lawyer's authorization?
Therefore, you must contact the lawyer seeking the information and explain that without an authorization from a client , the records cannot be released.
Do psychologists need to be represented at depositions?
For purposes of a deposition subpoena, it is becoming more frequent for a psychologist to have legal representation at depositions both to protect the psychologist and to help in the determination of what is appropriate for disclosure. If you receive a subpoena to appear at a deposition, it is best to contact your malpractice insurance carrier who may provide you with counsel for this limited purpose at no cost to you.
Why are psychotherapy notes separated from the medical record?
We based this decision on conversations with mental health providers who have told us that information that is critical to the treatment of individuals is normally maintained in the medical record and that psychotherapy notes are used by the provider who created them and rarely for other purposes. A strong part of the rationale for the special treatment of psychotherapy notes is that they are the personal notes of the treating provider and are of little or no use to others who were not present at the session to which the notes refer.
What would happen if psychotherapy notes were kept separately from other protected health information?
Comment: Many providers expressed concern that if psychotherapy notes were maintained separately from other protected health information, other health providers involved in the individual’s care would be unable to treat the patient properly…
What is authorization required for psychotherapy notes?
The relevant rule states: Authorization required: psychotherapy notes. Notwithstanding any provision of this subpart, … a covered entity must obtain an authorization for any use or disclosure of psychotherapy notes, except: To carry out the following treatment, payment, or health care operations:
What are psychotherapy notes?
To carry out the following treatment, payment, or health care operations:#N#Use by the originator of the psychotherapy notes for treatment;#N#Use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or#N#Use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual; and 1 Use by the originator of the psychotherapy notes for treatment; 2 Use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or 3 Use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual; and
What should be included in a psychotherapy note?
Many commenters believed that the psychotherapy notes should include frequencies of treatment, results of clinical tests, and summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date.
What is the privacy rule for mental health?
The Privacy Rule distinguishes between mental health information in a mental health professional’s private notes and that contained in the medical record. It does not provide a right of access to psychotherapy notes…. Psychotherapy notes are primarily for personal use by the treating professional and generally are not disclosed for other purposes.
What is the rationale for special treatment of psychotherapy notes?
A strong part of the rationale for the special treatment of psychotherapy notes is that they are the personal notes of the treating provider and are of little or no use to others who were not present at the session to which the notes refer. (65 F.R. 82622-23, emphasis added). II.
Why are psychologists getting more requests for records?
Some psychologists may be experiencing an increase in patient requests for their health records as patients become more active and involved consumers of health and mental health services.
What is the APA Ethics Code?
The APA Ethics Code and Record Keeping Guidelines support the patient’s right to access his or her records. Marketplace trends are expanding patient access to information in health records. Combined with the trend toward greater patient engagement in their health care, psychologists ought to familiarize themselves with HIPAA and relevant state laws. Practitioners need to understand what rights their patients have to access their own records, while also ensuring that they release the records in accordance with applicable law and the Ethics Code.
Can a psychologist limit access to a patient's records?
Under both HIPAA and state law there are instances when the psychologist may be entitled to limit patient access to information in the record, such as if the psychologist is concerned that allowing access would likely endanger the life or physical safety of the patient or another person.
Do you have to give a patient a copy of their medical records?
While patients do not have to give you a written request to see their records, it’s a good idea from a recordkeeping standpoint to ask them to sign an acknowledgment or otherwise document that you have given them a copy.
Do psychologists have to provide a copy of their records?
Although psychologists, or the organizations for which they work, maintain the original health records, federal and state law generally entitles patients to obtain copies of their records. So if a patient makes such a request, you generally must comply and provide the patient with a complete copy of his or her record.
