The Gillman HIPAA progress note is an efficient, and most importantly, HIPAA compliant progress note format. It was created by Dr. Peter Gillman in order to create a note format that follows HIPAA rules while also being easy to use.
Psychotherapy Notes vs. Progress Notes
To understand the value of the Gillman HIPAA progress note, it’s a good idea to understand how HIPAA treats clinical documentation. A Psychotherapy note, also known as a Process Note is used during a treatment session as a the private note of the clinician. These are almost absolutely private except under the following circumstances:
- A court order or a subpoena
- A lawful request from a government agency
- A lawful request from a law enforcement agency
Other than those limited circumstances, psychotherapy notes remain private to the therapist. Even a patient can not obtain these notes.
A Progress Note on the other hand is a record of treatment; it’s a documentation of the diagnosis, medications, clinical tests, types of treatment, prognosis and progress. A Progess Note is part of the client’s official records. The Gillman HIPAA note format is a style that can be used for Progress Notes and it complies with HIPAA requirements.
It’s important to note (pun intended) that psychotherapy notes and progress notes not be mixed together. Psychotherapy notes are specifically excluded from disclosure by HIPAA; if you create some kind of blended note, you’d be creating a record that could run afoul of disclosure requirements.
According to HIPAA rules, the following items are excluded from note confidentiality:
- Results of clinical exams
- Therapy session start and end times
- Modalities of treatment
The Gillman HIPAA note format
The Gillman format provides a useful template that prevents you from inadvertently including protected information (i.e. psychotherapy note content) on the progress note.
Here’s how it works
- Record the start and end time of your therapy session
- Record the treatment modalities used
- Summarize the symptoms, diagnosis, treatment plan and the prognosis.
Here’s what a paper version of the Gilman HIPAA Progress Note looks like: