Psychotherapy Notes

• The "psychotherapy note exemption" as defined by HIPAA says that your psychotherapy notes must be separate at the beginning of a chart.
  • They can not be created later after entries have been made.
  • They must be in a separate file to be considered for the "exemption".
  • As such, they are not part of the clinical chart.
  • When you release a chart the notes stay with you.
  • Charts then, are divided into Initial Evaluation, and Progress Notes in one file and Psychotherapy Notes in another.
• This actually is quite handy.
• With separate notes, review of them before the next session is now easy.
• Clinical Record Keeper™, Clinical Record Keeper Plus™ and Clinical Record Keeper-Mac™ have always separated these two categories.
  • Move between the two files effortlessly.
  • A major difficulty in many software programs is that you can't see the notes in sequence i.e., individual notes are in different places within the programs. That is not how I work and I will bet that isn't how you work either!
  • CRK programs solve that problem by making them in one file that scrolls.
    • You know exactly what happened when.
    • Movement in therapy is shown.
    • This file makes intelligent treatment documentation easier, let alone your own understanding of a case.
• Clinical Record Keeper™,Clinical Record Keeper Plus™and Clinical Record Keeper-Mac™ are organized like a clinician works and thinks.