Trust Risk Management Services, Inc.

Psychotherapy notes are afforded a higher level of protection from disclosure than non-psychotherapy documentation under HIPAA.  However, they must be kept separate from the medical record.  If they are intertwined, they lose that level of protection....  

Many practices or facilities are using Electronic Medical Records (EMRs) at this point, and it will continue to grow as time continues.  If you are documenting in an EMR, a few tips to keep in mind...

There are times you may need to be cautious about what to document.  Here are a few things to potentially avoid... 

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Documentation is critical to reflect care provided.  It is essential for current treatment, can be important years later for subsequent treatment, and can be used if a legal issue arises.  What should or should not be documented will depend on the patient, the type of care provided, and the specific circumstance of the case.

An addendum or correction is ok, and is actually needed to clarify the care or to correct misinformation.  However...