By Imperio, Winnie Anne
Clinical Psychiatry News , Vol. 29, No. 6
Two sets of records will be required.
NEW ORLEANS -- New rules prepared under the Health Insurance Portability and Accountability Act are going to change forever the way psychiatrists keep their medical records, Daniel H. Willick, J.D., said at the annual meeting of the American Psychiatric Association.
The HIPAA regulations confer protections for psychotherapy notes that may not have existed previously in a number of jurisdictions, noted Mr. Willick, who is a California Psychiatric Association attorney based in Los Angeles. The regulations, which are now in final form, are required to be implemented by April 2003.
The new regulations are going to require that two sets of records--medical records as well as psychotherapy notes, which are often called process notes--be kept to protect patient confidentiality.
The regulations define psychotherapy notes as "notes recorded by a healthcare provider who is a mental health provider documenting or analyzing the contents of conversation during a private counseling session that are separated from the rest of the individual's medical record."
Psychotherapy notes do not include information regarding medication; prescription; monitoring; counseling session start and stop times; modalities and frequency of treatment furnished; results of clinical tests; and any summaries of diagnosis, functional states, treatment plans, symptoms, prognosis, and progress to date. …