Psychotherapy Notes
Notes recorded by a mental health professional documenting or analyzing a counseling session, separated from the rest of the individual's medical record.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- HIPAA & Privacy
- Primary sources
- 2
- Workspace handoff
- compliance binder →
Where this comes up
Privacy officers and practice managers handle this — patient rights requests, accounting of disclosures, BAA reviews with new vendors, breach risk assessments after an incident, and OCR responses when a complaint lands. The 60-day breach-notification clock starts at discovery, not at investigation close.
Full definition
What it is in practice
45 CFR 164.501 defines psychotherapy notes narrowly — they must be kept separate from the rest of the chart and exclude medication prescriptions, session start/stop times, modalities, and treatment plans. Disclosure generally requires a separate, specific authorization per 45 CFR 164.508.
How it shows up in your practice
Most behavioral health practices integrate notes into the chart, in which case the heightened protection does not apply. If you want the protection, keep psychotherapy notes in a physically or logically separated file.
Sources
- 45 CFR 164.502 — Uses and disclosures of PHIhttps://www.ecfr.gov/current/title-45/section-164.502
- HHS — HIPAA Privacy Rulehttps://www.hhs.gov/hipaa/for-professionals/privacy/index.html
Set up separated psychotherapy-notes storage in the Compliance Binder
Open compliance binder →Related terms
- HIPAA & PrivacyDesignated Record SetThe group of records maintained by or for a covered entity that contains PHI used to make decisions about individuals.
- HIPAA & PrivacyAuthorization for DisclosureA written authorization signed by the individual permitting a covered entity to use or disclose PHI for a purpose not otherwise permitted by the Privacy Rule.
- HIPAA & PrivacyHIPAA Privacy RuleThe federal regulation at 45 CFR Part 164 Subpart E that governs the use and disclosure of PHI.
- Compliance Program42 CFR Part 2 (SUD Records)Federal regulation providing heightened confidentiality protection for substance use disorder treatment records.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryAuthorization for DisclosureA written authorization signed by the individual permitting a covered entity to use or disclose PHI for a purpose not otherwise permitted by the Privacy Rule.
- GlossaryDesignated Record SetThe group of records maintained by or for a covered entity that contains PHI used to make decisions about individuals.
- GlossaryHIPAA Privacy RuleThe federal regulation at 45 CFR Part 164 Subpart E that governs the use and disclosure of PHI.
- ComplianceBehavioral Health Compliance: 42 CFR Part 2 + HIPAA TogetherHow SAMHSA's 42 CFR Part 2 framework for substance use disorder records overlays HIPAA after the 2024 final rule alignment, and what behavioral health practices must document.
- Glossary42 CFR Part 2 (SUD Records)Federal regulation providing heightened confidentiality protection for substance use disorder treatment records.
- RegulationHIPAA Accounting of Disclosures (45 CFR 164.528)Individuals may request an accounting of disclosures of their PHI made by a covered entity in the prior six years, with a defined list of exclusions.
- BillingBusiness Associate Agreement Checklist for Small PracticesA working checklist for small practices to identify which vendors need a Business Associate Agreement, what clauses the BAA must contain, and how to track them.
- SRAHIPAA Patient Right of Access: A Small-Practice WalkthroughHow 45 CFR 164.524 governs patient access to their records, the 30-day rule and 30-day extension, the limited fees a practice may charge, and the OCR Right of Access Initiative.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.