See Therapy Notes & the Clinical Record.

The Sample Form below is created to help you think about how you can develop psychotherapy records that meet HIPAA requirements, while at the same time limiting the amount of information you record.  

Restrain your impulse to the narrative and substitute symptoms, status, and other "content neutral" material in your record.  

Remember that what you record may be subject to audit.

Remember that your clinical record is available to your client to inspect.

Note that the last line on the form is only intended for you to use if you anticipate that your clinical record will be routinely shared with someone other than yourself.

 Keep your psychotherapy notes elsewhere.

Prepared by Michaele P. Dunlap, Psy.D. for Pragmatics of HIPAA Training 2-28-03


CLINICAL RECORD

Client:_______________________________________                                                               

 

 

Clinician: ____________________________________

 

Session Date

 

Start Stop Times

 

Mode Tx

 

Summary recorded this session: (T)Tests/Results, (M) Med.(D)Diagnosis, (S)Symptoms, (F) Functional Status (TxP)Treatment plan, (Prog) Progress to Date (E)Prognosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Per Federal Regulation  the above information is documented at each client visit, and may  be used or disclosed upon specific written consent of the client or the client=s authorized representative for treatment, payment or healthcare operations. No other information about this client will be released by this mental health professional/mental health care entity unless specific, fully informed authorization from the client or an authorized representative is obtained in writing, or as otherwise allowed or required by law. 

Statutes and regulations in this State may  be more restrictive than Federal Regulation, further limiting disclosure of the above and other individually identifiable health information. 

AS THE RECEIVING ENTITY, YOU MAY BE SUBJECT TO CIVIL AND FEDERAL CRIMINAL PENALTIES FOR IMPROPER RE-DISCLOSURE OF THIS INFORMATION.