HSP Documentation & Record Keeping 3 — Questions and Answers
Question 1: An electronic health record system used by a psychologist is breached, exposing 600 client records. Under HIPAA's Breach Notification Rule, the psychologist must notify:
- Only the affected clients within 180 days
- Affected clients, HHS, and prominent local media within 60 days (Correct answer)
- Only HHS within 30 days with no obligation to notify clients
- The state licensing board within 24 hours
Correct answer: Affected clients, HHS, and prominent local media within 60 days
Breaches affecting 500 or more individuals require notification to affected individuals, HHS, and prominent media outlets in the state, all within 60 days of discovery.
Question 2: According to APA Ethics Code, records should be maintained in a manner that:
- Allows for the psychologist's personal convenience above all else
- Facilitates provision of services and meets legal, regulatory, and institutional requirements (Correct answer)
- Prioritizes insurance reimbursement documentation over clinical accuracy
- Ensures records are inaccessible to all third parties under any circumstance
Correct answer: Facilitates provision of services and meets legal, regulatory, and institutional requirements
APA Ethics Code 6.01 requires that psychologists create, store, and dispose of records to facilitate service provision and to meet legal, regulatory, and institutional requirements.
Question 3: A psychologist receives a request from a client's new therapist for a 'transfer summary.' The psychologist does NOT have a signed release on file. The psychologist should:
- Send the summary because it is in the client's best clinical interest
- Obtain a signed authorization from the client before releasing any information (Correct answer)
- Call the new therapist to verbally share the information without documentation
- Refer the new therapist to the client's insurance records
Correct answer: Obtain a signed authorization from the client before releasing any information
Without a valid signed authorization from the client, the psychologist cannot release records or a transfer summary to another provider, even for clinical continuity purposes.
Question 4: Which of the following BEST describes the concept of 'portability' in the context of client records?
- The ability to move records to cloud storage for easier access
- The client's right to obtain a copy of their records and transfer them to another provider (Correct answer)
- The psychologist's ability to access records from any device
- The requirement to convert paper records to electronic format
Correct answer: The client's right to obtain a copy of their records and transfer them to another provider
Portability refers to clients' rights under HIPAA and ethical codes to access and obtain copies of their own health information and authorize its transfer to other providers.
Question 5: When a minor client turns 18 during treatment, which of the following is the MOST appropriate documentation practice?
- Immediately destroy all records created during the minor period
- Obtain a new authorization from the now-adult client before releasing records to parents (Correct answer)
- Allow parents unlimited ongoing access since they held legal guardianship previously
- Transfer all records automatically to the adult client's new chart without any documentation
Correct answer: Obtain a new authorization from the now-adult client before releasing records to parents
Once a client reaches the age of majority, they assume full rights over their records, so a new authorization must be obtained from the adult client before releasing information to parents.
Question 6: A psychologist discovers an error in a client's clinical record. The APPROPRIATE correction procedure is to:
- Delete the original entry completely and rewrite it
- Use correction fluid (white-out) to cover the error in paper records
- Draw a single line through the error, add a correction note with date and signature (Correct answer)
- Create an entirely new record and discard the old one
Correct answer: Draw a single line through the error, add a correction note with date and signature
Proper error correction in paper records involves drawing a single line through the mistake, noting the correction with the date and clinician's signature, preserving the original entry's legibility.
Question 7: In forensic psychological work, documentation standards differ from clinical practice primarily because:
- Forensic records are protected by stronger confidentiality rules than clinical records
- Forensic reports must anticipate scrutiny by attorneys, judges, and opposing experts (Correct answer)
- Forensic psychologists are exempt from state record retention laws
- Forensic clients have waived all rights to access their own records
Correct answer: Forensic reports must anticipate scrutiny by attorneys, judges, and opposing experts
Forensic documentation must be thorough, objective, and able to withstand adversarial cross-examination because reports will be reviewed by legal and judicial stakeholders.
HSP Documentation & Record Keeping 3
An electronic health record system used by a psychologist is breached, exposing 600 client records.
Under HIPAA's Breach Notification Rule, the psychologist must notify: