Psychotherapy Notes
Date of Publication:
3/13/2019
Definition:
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, group, joint, or family counseling session and that are separated from the rest of the individual's medical record. 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.
Source of Definition:
Implementation of the Health Insurance Portability and Accountability Act Privacy Rule in DOD Health Care Programs
Related Glossary Terms:
Psychotherapy Notes | Psychotherapy Notes