Use and Disclosure of Psychotherapy Notes

Statement of Policy

Washington University and its member organizations (collectively, “Washington University” or “WU”) are committed to conducting business in compliance with all applicable laws, regulations and WU policies. As part of this commitment, WU has adopted a policy to ensure that the WU Workforce who create, Use, or Disclose Psychotherapy Notes, as defined by HIPAA, are compliant with the HIPAA Privacy Regulations.

Scope of Policy

The scope of this Policy includes all Psychotherapy Notes created, Used or Disclosed by WU and carries with it the expectation that the clinician providers who create, Use or Disclose Psychotherapy Notes will take a prominent role in the application of this Policy.

Policy

1) Use or Disclosure of PHI with Authorization.

a) Except as provided in c), WU must obtain a valid, written Authorization for any Use or Disclosure of Psychotherapy Notes. Psychotherapy Notes are notes:

i) recorded (in any medium) by a Health Care Provider who is a mental health professional;
ii) documenting or analyzing the contents of conversations occurring during a private counseling session or a group, joint, or family counseling session, and
iii) that are separated from the rest of the Individual’s medical record.

b) The definition of Psychotherapy Notes excludes 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. These do not constitute psychotherapy notes and are considered part of the medial record and subject to any restrictions that apply to Use or Disclosure of those records.

c) An Authorization is not required for the Use or Disclosure of psychotherapy notes related to treatment, payment, or health care operations.

d) An Authorization to Use or Disclose Psychotherapy Notes must be written in plain language, and must contain all of the following elements: See Exhibit A.

i) A specific and meaningful description of the information to be Used or Disclosed;
ii) The name or identification of the persons or class of persons authorized to make Disclosures of Protected Health Information (PHI) and to Use the PHI;
iii) The name or identification of the persons or class of persons authorized to receive Disclosures of the PHI and to Use the PHI;
iv) A description of each purpose of the Use or Disclosure;
v) An expiration date or event, or a statement, when appropriate;
vi) The Individual’s signature (or that of his/her authorized representative as determined by Missouri law) and date. (Note: If the Authorization is signed by an authorized representative, include a description of the representative’s authority under Missouri law to act for the Individual);
vii) A statement that the Individual may revoke the Authorization if done in writing to the Privacy Officer or Privacy Liaison of the Business Unit; except to the extent that Use or Disclosure of the PHI occurred pursuant to such Authorization before it was revoked.
viii) A statement that WU may not condition Treatment, Payment, enrollment or eligibility for benefits on whether the Individual signs the Authorization, if the Authorization is for Use or Disclosure of Psychotherapy Notes; but that an Individual may not participate in a clinical trial that includes Treatment unless there is a signed Authorization.
ix) A statement that information disclosed under the Authorization could potentially be redisclosed by the recipient and would no longer be protected under HIPAA.

e) An Authorization for any Use or Disclosure of Psychotherapy Notes, must be separate from any other Authorization except one authorizing Use or Disclosure of Psychotherapy Notes.

f) The Individual must be provided with a copy of his/her signed Authorization.

 2) Individual’s Access to Psychotherapy Notes.

a) Individuals do not have the right to access a provider’s Psychotherapy Notes.
b) The denial of access to Psychotherapy Notes is an unreviewable ground for denial. In other words, the denial is not appealable.

Creation Date: November 22, 2002
Effective Date: April 14, 2003
Last Revision Date: August 30, 2013