? Does anyone know who "owns" therapy notes?

I'm sorry if I am posting a senistive subject. I am still getting used to posting to a board and reaching out to other people for help is very hard for me.

?Does anyone know who owns the therapy notes, what happens to them after a patient quits therapy?

About 23yrs ago, I was in therapy with the same T for 10yrs. When I quit, I asked him about my file. He said that he had copied it and kept a copy at his home, as well as, in the group that he practiced.
He said he had been writing a book and was going to include some of the notes plus the personal drawings and creations that I had made during the last 10 years. He was a former publisher and when I started therapy had only been a T for a year. He said that he would change my name in the book to protect my privacy. That he had been compiling "interesting" cases and working on this book. The book was not intended for the medical community but rather as a book for general public. It souned sort of like a self-help, enteraining "can you believe this" book. He had kept all his publishing contacts in Chicago and they thought that that the book would sell. That there wasn't anything that I could do about it

Anway, it really messed me up for a long while - I just felt violated in some way. I believe this is the first time I've even been able to acknowledge it. I put it out of my mind and any T that I went to after that I insisted that there be no "notes". That was a deal breaker for many new therapits that I sought out - never told them why but just insisted.

I've quit therapy again after 3 years and I want a copy of her diagnosis because of SSDI purposes - I don't even know if she will be doing therapy when renewal time comes up and she is by herself so no practice for the documentation to stay around.

So my questions are:
? Who owns the therapy notes, what are done with them when you quit
?should I be able to get something from my therapist with my diagnosis, I always paid in cash with no receipt.

I'm not going right back into therapy so she can't send them to a "new" T.

I would welcome any information on this subject. If I need to do something different with my posts, just let me know.

Thanks much,
Lu

OMG, I would not only have felt violated by what your first T did to you, I would have reported the jerk! I'm so sorry that happened to you.

Your medical records are YOURS. You have a right to ask for them and a right to receive them. Doctors are required to keep copies for a certain amount of time, I believe, but that doesn't mean they can keep copies from you!

Wow. I just cringed when I read this. I'm so, so sorry a T did that to you!! It's hard enough to find somebody you can trust. To find out you *can't* trust them had to be devastating!

Good luck to you.

Candy

Hmm... Actually... I'm not sure that they are yours but I'm fairly sure that there are restrictions on what a clinician can use them for...

I'm fairly sure... That the clinician owns them. Though if you see someone in the public service then it might be a bit different... My notes were on my mental health file so the clinician certainly didn't get to keep them when I left.

I'm not sure that your clinician was allowed to photocopy them for his own personal use... I would say that your clinician notes are made in order to facilitate your clinical care. Your therapist photocopying them for their personal use without your permission sounds off to me...

I'm fairly sure that consent must be given before your clinician could use your notes for something like that. That being said... Sometimes people do do wrong...

I'm from NZ, however, so things could run differently in the US. I'm fairly sure that the client doesn't own the notes, however, as the client has to apply to be able to see them and the client doesn't get to keep a copy usually (though I've requested this before and it has been granted).

The point of clinical notes...

Is professionalism. Why? So that if something happens to you (you commit suicide or a crime or someone hurts you or kills you or something) then your notes are there. This is to protect your clinician. If you were to commit suicide and your clinician had to appear in court and say why they didn't do anything to prevent you and your clinician had kept no formal notes... Your clinician would look like an incompetent @ss.

Same goes for cases where the client sues the clincian for inappropriate conduct or something like that. Clinician appears in court and there aren't any formal notes... Your clinician looks like an incompetent @ss.

I would say that it would be really very hard to find a competent, professional clinician who would agree to see you on the condition that they don't keep notes.

That being said typically there can be some sort of comprimise and I'm fairly sure that a competent and professional clinician should understand that you have been burned about this and it is understandably something you are sensitive about. They should also be able to reassure you that the notes are for them to help you in your progress and that they will not be disclosed to third parties without your explicit consent unless they are ordered to disclose them for a court of law...

The files are the property of the therapy agency. the original files never leave the therapy agencys unless they put them into a storage filing system or shread them.

The client can at any point request to see those files or recieve a copy of the files but the original file on the client remains with the therapy agency.

I have had 19 different therapists and have moved many times and each time the original file was legally considered the agencys property.

When I requested my file I was given a copy of the files either personally and or by my new therapist photocopying the copies she recieved.

When my child went into foster care DHS was able to also recieve copies of my mental health records. The originals were not released to them only photocopies. When I asked the DHS caseworker why she didn't get the originals she told me legally therapy files are the property of the therapy agency.

When she went to court to get my original files because she felt something was missing from the copies the court said the original files belong to the agencys not me so her trying to have the court requiring me to sign a release form to have the originals turned over to her when she already had copies was denied. She could charge me with being a danger to myself at that moment and start court proceedings to have me involuntarily committed in which case the original files will be supeniaed and the judge would go through the copies and the original to varify that she recieved a complete copy but if she was going to waste the court time she better be sure that I was in fact at that moment suicidal or self injuring.

As for session notes that a therapist writes during the therapy sessions what happens to them depends on the agency protocals. Most times they are entered into the file unless the agency has specific session notes form in which case the notes are rewrote into the spaces provided on the agency form. and agency forms are usually real basil little to no detail - name of client, date, diagnosis, and a sentence or two of what was done during the session for example the last time I saw my form that went into the file it said something like -

(name) (date) talked about PTSD issues today and worked on some coping tools for that. Client is also journaling and using artwork to help herself.

Yes you should be able to get the information that you need just by contacting the therapy agency that you recieved your therapy from. DHS was able to get copies of my therapy records from over 20 years ago by court order. They may want you to sign a release of information form so that they can release your diagnopsis and so on to SSDI. Thats how SSDI was able to recieve my diagnosis and so on along with my going to see the therapy people that SSDI required me to go to to varify my records.

There are different types of note taking done by mental health practitioners.

Notes placed in the "official" medical record are property of the clinic or hospital, but patients have a right to access these records.

"Other" notes filed in other types of patient files or records are not accessible to the patient. These are purposely withheld from patients' "official" record for legal reasons (I think). There may be time limits for disposal of these types of notes, but I'm not sure. (There should be time limits!)

Not everyone takes notes.

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He said he had been writing a book and was going to include some of the notes plus the personal drawings and creations that I had made during the last 10 years.

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This is a violation of doctor/patient confidentiality!! For him to use your drawing WITHOUT your consent is plagerism! Those drawing as YOURS!!

freewill . . . that counselor is unethical.

Research your state's laws on "Breach of Confidentiality."

You can also check with HIPAA. (If that counselor obtain your info while also working at a clinic/hospital accepting government funds, like Medicare, then that clinic/hospital can be reported for a HIPAA violation.)

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A breach of confidentiality is a disclosure to a third party, without patient consent or court order, of private information that the physician has learned within the patient-physician relationship. (source )

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I am so sorry that this happened..My first therapist who I did art therapy with took my drawing book and made a disc of all of my pictures without telling me that was what he wanted it for..when I told him how much it upset me at a later session he took the disc out and broke it in front of my face scattering pieces all over..he was angry and I ran out..I understand how hurtful it was for you..I once requested my file from a T and all I received was the paperwork between him and my insurance company..I was told his personal notes were his own..the paperwork I received was really nothing..I am not sure if is a state by state thing..take gentle care.

- I - have always had complete access to -MY - therapy records both the official and the one that -MY - therapists keep separate because DHS is a part of - MY - life. absolutely nothing is and or has ever been withheld from - ME -.

There are times in the past when - I - have asked to see ALL files kept on and about and for - ME - and in the cases where the therapist had put things in them that they had not discussed with - ME - they gave me access to those files on the understanding that - I - read them on therapy agency premises whan - MY - therapist was on location so that if - I - had a problem with what was in the files for legal reasons and diagnostic reasons and so on -I - had access to - MY - therapist who would go over the file content with - ME - none of - MY - 19 therapists in the 20 plus years that - I - have been in therapy refused - ME - access because they didn't want - ME - to know something they had wrote in the files for legal reasons and so on.

What they usually say to ME is

"there are some things in the file that we have not discussed as of yet so I will go through the file with you or you can read it in an unused room and I will check in with you between sessions."

And - I - go in to the agency on the agreed upon time and read - MY - files. - I - can also at that time make copies of anything that -I - want to take home with - ME -.

For those that get upset by capitalization - MY capitalization is not for yelling purposes. I am just making sure -MY - I - statements are clear.

Yeah, I've had a look at my file notes too. I needed to request to see them in writing and it took a while for them to photocopy them all. I wasn't seeing a clinician at the time so I was allowed to go in and pick them up and take them away.

Apparantly they asked previous clinicians whether that was okay before they photocopied the notes, however.

I'm fairly sure that you do have the right to view your file. That can only be denied if your clinician believes that viewing information in your file could result in harm to you or if your clinician believes that viewing information in your file discloses confidential information about another (such as the identity of a person who phoned crisis assessment because they were concerned about you) or something like that.

I have read that viewing your file notes in the presence of your clinician is optimal because your clinician is there to make sure you are okay with what you have read.

That being said I was grateful to get to take them away and be able to digest little bits at a time (I have many files)...

It was hard for me to process some of the stuff that I read, however.

I think there might well be privacy laws on how your file is supposed to be stored. I'm fairly sure that your therapist can't take them home unless there is a specific reason and they are kept in a locked cabinet or something like that.

I think there is a time after which notes are supposed to be destroyed too... There might be a minimal time that they are required to be kept for... And there might be a maximal time... But I'm not sure on this...

Thank you one and all... I feel better ... just knowing that I have rights. I am going to presue the notes from my last therapist - I need them for SSDI! I am glad that I am not alone in feeling what my first T did was wrong. My file was very thick, he made about 3 pages of notes a session. I was just so angry at the time but there wasn't anyone to talk to. Having computers and having boards like this takes away my feeling of isolation. so thanks again...
Lu