Protect yourself - Order your therapy notes and health records

Hi community,

I highly recommend that everyone in therapy order their health records / therapy session notes. My personal experience has shown that they can be altered, falsified, deleted, etc. This is a common occurence when there are complaints and lawsuits. You need to protect yourself.

This information is extremely sensitive and is considered evidence and can be used to harm you. It is your right to see what is written and have copies. You can also request changes and or add notes of your own if you disagree with anything that is recorded.

Get them sooner than later.

Thanks,
HD7970GHZ

I didn’t know that therapy notes were something that you could request and receive.

Same here, how do you go about requesting them?

Are you implying that we would end up in court, for medical or therapy notes to be used as evidence? Do you mean if we are accused of having committed a crime?

I just reported my ex-t. Ex-t altering or falsifying my records to her favor had been an on-going concern of mine.

I had thought about requesting a copy of my records from ex-t but by then it was too late. She would have had them altered before sending me a copy anyway.

For anyone in the UK:

https://ico.org.uk/for-the-public/health/

"an individual’s right to object to processing that is likely to cause or is causing damage or distress".

I think I'd want to know, but not sure if he would actually show me. I think i'll bring it up on tuesday.

I wouldn't want them... no desire to ever do anything with legal/reporting etc. I would hate to read about myself.

It's a good idea for those who may want to have it in case though.

I requested my records from the hospital Health Records department. All I had to do was sign a document and pay for the copies.

Reading my records has helped me heal and understand how clinicians think. A lot of the content was different from what I remember. Some was inaccurate. I suspect some of the residents got me mixed up with other patients. Initially, I was surprised, but soon realized they were people who only get the chance to see one small side of me. I doubt they deliberately lied about it and that it was actually due to cognitive bias. What would lying serve? No one committed any crime.

This has changed how I view psychiatry and therapists. They are people like me. Having a degree and being an expert doesn't imply they are superior beings. I refuse to give anyone that power. Reading my records made me realize this.

Now, my two doctors must communicate with me and not withhold any information especially my records. I made this very clear when I first met them. Both have no problems giving copies of my records whenever I ask, which is rare.

To clarify, in the US you are allowed to view your medical records. If you want copies, providers may charge you and they are allowed to do that. Process notes/therapy notes don't necessarily fall under that category depending on how a T stores their documentation. Additionally, mental health providers are allowed to refuse to let their clients see their notes if they believe that it would be harmful.

In the spirit of therapy, you can ask anything of your T, but in general they won't alter their documentation. You can have an addendum added however, although in certain circumstances they can refuse.

I personally don't see a need to request and keep (or read) my therapist's notes, but I can understand how others might. But, it's important to know that it probably won't be as easy as asking and then a day later getting copies.

What if my ex-T just wrote chicken scratch on note paper and never typed up a single professional document on each session? That is how my ex-T rolled.

I recommend keeping a set of your own visit notes (therapy and medical) so that there is not just one 'source of truth' documented.

And of course the provider knows what's best for the client. Speak volumes about warped assumptions.

I wanted, at first, to see my previous T's notes. He offered them to me, and I refused. I decided that I didn't want to know his opinion of me, as in therapy, he had no idea who I was. I didn't want to read his misguided notions.

That sounds like a dream come true MoxieDoxie!!

I heard that this is against college policies and considered unethical. At least, that is what my last therapist told me. I haven't actually seen this or investigated it.

Could be any number of reasons. They can be subpoena'd, should be reason enough to warrant interest.

This is an example of what goes on with our health records.

Canadians' mental-health info routinely shared with FBI, U.S. customs | CBC News

Canadians with mental illnesses denied U.S. entry | CBC News

Thanks,
HD7970ghz

I thought some state laws trump federal laws? In a circumstance where T could use their discretion and not give away the notes, I also read they would have to give the notes to the Ts current therapist. That way, the current therapist would be able to go over the info with the client and support them (if it was hard to read and/or “harmful”). I’m having trouble understanding what is considered “harmful”. In my experience, I’d want to know whether it was hard to read or not.... just like a medical notes, I don’t see reading therapy notes as causing damage, unless the therapist was lying. In that case, that would be a problem with the therapist and not me reading the notes. I was actually thinking about reaching out to my old T for her notes, but I’m not sure if she’s legally obligated to sending me them since she told me she’d never contact me again. Does anyone know if Ts are legally obligated to provide their notes in certain US states? And if so, which ones?

I think this is an important question.

This looks like a good source:

Individual Access to Medical Records: 50 State Comparison | Health Information & the Law

Comparative map that shows the medical record access requirements for all 50 states plus DC. It indicates which is stronger--states or HIPAA, but you may have to look at the state links, which provide summary law, for guidance on psychotherapy notes.

For example, here is Oregon law (same as HIPAA):

Or. Admin. R. 847-012-0000 - Patient?s Access to Medical Records | Health Information & the Law

New Mexico (preempted by HIPAA):

Release of Medical Records ? N.M. Code R. § 16.10.17.8 | Health Information & the Law

In states that aren't prohibitive, a therapist can simply have a set of notes they don't share with anyone and no one would even know about it.

I personally wouldn't see a therapist who puts information about my sessions into a computer.

I'm not sure if this is to do with cultural differences. I'm not anticipating ever being in a courtroom in my life. I think most people are not. If I had married a very abusive partner and there was a custody battle (I have a family member who was in this situation) then I would rely on objective evidence e.g. police reports from when they had been called out. Therapy or medical notes would really not be relevant, I think. It's hard to imagine a scenario where my health would have anything to do with the matter in hand. Unless I have gone totally mad and started harming people, but in that case I imagine the medical and therapy notes would be very much relevant and I hope they would help me to be sectioned and get the help I would clearly need at that point.

I appreciate your explaining this. People think HIPAA requires therapists to provide them with psychotherapy notes, which it does not. They can ask for and receive progress notes which are medicines, meeting times and dates, diagnosis, etc.-- not usually the ones you think of when your therapist is sitting across from you scribbling into his notebook. Your therapist doesn't have to take those kind of notes or keep them or turn them over to you.

Yes, you are correct, state law does trump federal law but only when making laws stricter. For example, the FBI could raid every dispensary in Colorado because even though marijuana is legal in the state it's still illegal at the federal level. In this case, I don't think that laws can loosen the restrictions on HIPAA, only make them tighter.

And yes, there is recourse for the client if the therapist wants to deny access. To expand a little, I believe that the client can have it go to any therapist, not just one that they're seeing currently. And that therapist then decides what to share and not share.

I think your T would be obligated to respond to your request, but I don't think they would have to share their psychotherapy notes in all honesty. They are required to share treatment records though, and those include diagnosis, prognosis, medication, functional status, modalities, frequency, etc.

I would just point out that the OP appears to be posting from Canada. Different health system, different laws from US.

Indeed I am in Canada.

It’s also not consistent province to province (or territory) just as state laws vary.

I'm in the UK, and when I asked one of my therapists if I could see what she had written about me, she was very offended and refused. I only asked because she always misinterpreted what I was telling her, and I was curious about my notes. She eventually half relented, and when our sessions ended, showed me the letter that she would be sending to my doctor. I read it in front of her and I wasn't happy with what she had written because she blamed me for not making any progress. It upset me, but I didn't say anything.

Also, when I was being assessed prior to therapy, the assessor had my previous therapist's notes and would often disagree with with what I was telling her, saying that what was written down was completely different. This concerned me tremendously, because the information was untrue and I had no way of correcting it.

That was more than a decade ago, but this thread has made me wonder what else has been written about me - and what I can do to ensure that any other mental health professionals I deal with, will listen to what I have to say without bias.

My ex-T is quadriplegic with the ability to have control of his head and control of his left had (with which He can write , with a lot of different aids). Needless to say, he cannot use a typewriter or computer).

What is this “against college policies and considered unethical?” Note-taking? Failure to deliver digital notes?