Behavioral Health Record
The protected clinical record documenting mental health and substance use services, subject to stricter confidentiality regulations than general medical records.
Full Definition
A behavioral health record (also called a mental health record or substance use record depending on content) is governed by both HIPAA and, for substance use content, 42 CFR Part 2, which imposes more stringent consent requirements than standard medical records law. Editors producing clinical forms, consent documents, or policy materials must be alert to whether 'behavioral health record' or 'mental health record' is the preferred institutional term, and must not conflate these documents with general electronic health records (EHRs) in language that implies the same disclosure rules apply.
Usage
Usage note: 'Psychotherapy notes' are a legally distinct subset of the behavioral health record with heightened protections under HIPAA. Do not use the terms interchangeably.
In Context
- "The release-of-information form specified that the behavioral health record required a separate authorization from the patient before any disclosure." — Release of information form
- "Editors should verify whether the document refers to 'behavioral health record' or 'psychotherapy notes,' as the latter carries an additional layer of federal protection." — Compliance document review