Psychotherapy Treatment Records

The Social Security Administration (the “SSA”) uses the HIPPA definition for “psychotherapy notes,” which are also known as session or process notes. Mental health professionals document their conversations of counseling sessions with notes, and according to the SSA, it “recognizes the sensitivity and extra legal protections that concern psychotherapy notes and does not need the notes." The SSA excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date, from psychotherapy notes. 

Most mental health providers have one set of treatment records, which leaves two choices. First, the records that would be considered psychotherapy notes can be blacked out. Alternatively, the mental health care provider can prepare a report that details the critical current and longitudinal aspects of the patient’s treatment and their functional status. Most Social Security Disability attorneys provide mental medical source statements that provide the information consistent with the second option. Nonetheless, the SSA always insists on having the actual treatment records. 

The problem with supplying the psychotherapy notes is that the SSA cherry picks comments out of context to argue that the claimant’s mental impairments are insufficiently severe to be disabling. When the SSA demands my client’s psychotherapy notes, I offer to provide them if they confirm in writing that the information from their website is incorrect. I also offer to supply a report providing whatever details regarding the critical current and longitudinal aspects of the claimant’s treatment and functional status that the SSA claims was omitted form the mental medical source statement. 

I represent a claimant with anxiety and depression whose application was approved today less than two months after it was submitted. The SSA insisted on a consultative examination (“CE”) for my client because I only submitted mental medical source statements and narrative reports. After I submitted a letter discussing the above, the SSA withdrew the CE demand, and approved the application.