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A Composite of Information Regarding Documentation for FM BH Providers
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12/10/2018 at 6:35:58 PM GMT
Posts: 21
A Composite of Information Regarding Documentation for FM BH Providers

The long narrative below is a composite of information I provided to our own embedded Family Medicine BH providers regarding documentation/records. The information applies to all BH providers in systems with EHR's, whether embedded or not. All the underlines are active links to resource info: 


The bottom line premise is that although we've traditionally combined the two, a psychotherapy/counseling note (AKA process note) and a progress note ( not the same thing. We should put only progress notes in the EHR for SO many reasons (not the least of which is we're not required to do otherwise - not by most organizations not by APA, not by TSBEP, not by insurers, not by Texas law.) You are not violating ethics or privacy to separate the two of these, nor, in most cases violating any laws. Since State laws differ, The Trust, working with APA, has developed EHR templates for use by psychologists - these also cover state-specific requirements for patient records. (

By definition, anything that appears in the EHR is considered by HIPAA to be a progress note, and, although it's still private info under HIPAA, it does not have "special" protection afforded to process notes. Therefore, only the following belong in the EHR: Start and stop times, type of treatment, results of any assessments, diagnoses, functional status, treatment plan including goals and timelines, current symptoms, prognosis, and progress to data. Everything else, including (1) extensive social history (beyond basics and what's already in the chart), (2) anything not pertinent to medical treatment or necessary for insurance reimbursement, (3) justifications for formulations, (4) issues you're considering, (5) your personal musings about the patient, (6) certain details of the patient's life, etc., should go in psychotherapy/process notes that are held in a locked cabinet/drawer (or in your memory if your State doesn't require you to keep written ones). These latter notes do have special HIPAA protection and can be obtained by other parties (including the patient) only with your permission or by court order. 

Things to ponder:

* Many psychologists were taught to justify, rationalize or explain things like diagnoses and other formulations - these don't belong in a progress note and could give you grief in certain situations. Also, no one who reads them cares - your notes aren't going to be scrutinized by a former professor. We need to challenge some of the conventions of our training.

* Progress notes are routinely sent by healthcare systems to payers to justify reimbursement. Do you want an insurance company rep reading process notes you've included in the EHR? * The trend is toward open notes - many systems already allow patients to access all documentation notes in the EHR. We're going to have to be more aware of documentation.

* Some healthcare systems, including ours, ask permission before releasing our EHR notes, but this may be false security, given the growing tendency of healthcare systems to allow access to each other's patient records. This does not preclude your keeping process notes where you can put all the details you're used to recording, and which have special privacy under HIPAA, but keep them out of the EHR.

* Look at one of your EHR notes and ask yourself if you'd want your patient to read it, if all information there is pertinent to medical treatment or required for reimbursement. Again, go back to those templates and stick to them for the EHR notes.

See highlighted below. 

The following are resources I found in a Google search covering recent years (since EHRs and integrated care) - and there are plenty more where these came from. The multiple books I have on PC and health psychology also make these points and are calling for training programs to get up to date, I might add. 

1. From Blount (the guru of PC psychology): "Perhaps learning to document using a computer is a good tool; the skill that is most important is learning to do primary care notes. The "process recording" that is used in training is almost the opposite of what is needed in primary care. These need to be terse, clear summaries of the issues, progress and plans of the session. Students need to learn the difference between "psychotherapy notes" and "progress notes" and learn how to record in the latter and eschew the former." 

2. From American Academy of Pediatrics ( "The HIPAA definition of a "psychotherapy note" is quite restrictive. A psychotherapy note per HIPAA ...[is a] written analysis of a conversation that occurred during a private counseling session that is maintained separately from the medical record. These written analyses serve as working process notes about sessions to assist the therapist, and are not put into the medical record billing document. Anything which appears in the patient's medical record cannot be categorized as a psychotherapy note under the HIPAA rule [and therefore does not have special protection]. Specific content that has been listed as not falling under the "psychotherapy note" protections include medication management information, counseling session start and stop times, the type and frequency of treatment delivered, the results of clinical tests, diagnosis summaries, functional status, treatment plan, symptoms, prognosis, and progress to date. 45 CFR 164.501. 

3. From APA ( "It is important to note that multidisciplinary records may not enjoy the same level of confidentiality generally afforded psychological records. The psychologist working in these settings is encouraged to be sensitive to this wider access to the information and to record only information congruent with organizational requirements and necessary to accurately portray the services provided. In this situation... the psychologist may keep more sensitive information, such as therapy notes, in a separate and confidential file." 

4. From APA ( : "Basic records, often called progress notes, cover the who, what and when of treatment. These records ... should include such information as dates and types of services, assessments, intervention plans, consultations, testing reports, releases of information, consent forms and any supporting data... In addition to these progress notes, psychologists can keep psychotherapy or process notes for their own use. These notes include a little bit more detail that some therapists like to include, perhaps information they consider relevant to hypotheses or analyses about behavior change." 

5. From HIPPA ( "Generally, the Privacy Rule applies uniformly to all protected health information, without regard to the type of information. One exception to this general rule is for psychotherapy notes, which receive special protections. The Privacy Rule defines psychotherapy notes as notes recorded by a health care 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. Psychotherapy notes do not include any information about medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, or results of clinical tests; nor do they include summaries of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. Psychotherapy notes also do not include any information that is maintained in a patient's medical record. See 45 CFR 164.501. 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. See 45 CFR 164.508(a)(2)." 


Best, Judy

Last edited Monday, February 4, 2019

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