Can Patients Access Their Psychotherapy Notes? |
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Patients generally have a right to access their official clinical records.
Patients do not have a right to access their psychotherapy notes.
Patients can ask questions even when they cannot access psychotherapy notes.
Most conflicts over access to records can be resolved through friendly discussions.
When patients receive services from mental health professionals (MHPs), they have a right to informed consent (Barsky, 2023). Informed consent includes the right to understand what kinds of records their MHPs keep, and whether they have the right to access their progress notes, psychosocial assessments, or other documentation provided by their MHPs. Professional ethics for MHPs all recognize the importance of informed consent, privacy, and access to information about services provided (ACA, 2014; APA, 2017; NASW, 2021).
Under the federal Health Insurance Portability and Accountability Act (HIPAA), patients generally have a right to see their “protected health information,” which includes clinical records maintained by MHPs (U.S. Department of Health and Human Services, 2024). Under this same law, however, there is an exclusion for “psychotherapy notes.” The purpose of this article is to distinguish between clinical records (which patients have a right to access) and psychotherapy notes (which HIPAA excludes from the access rule). The distinction can be confusing, particularly for people who are not familiar with the different types of records that mental health professionals may keep. State laws may also offer patients the right to access their records; however, state laws cannot override federal laws, such as the exception for psychotherapy notes (Barsky, 2024).
What Are Psychotherapy Notes?
Under HIPAA, “Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session........