Documentation & Record Keeping Flashcards

A psychologist is closing their private practice. Regarding client records, they are ethically obligated to:

Answer: Notify clients, arrange for record storage or transfer, and ensure continued access

When closing a practice, APA ethics require notifying clients, making arrangements for proper record storage or transfer, and ensuring clients can access their records.

A psychologist's progress note states: 'Client appears depressed.' This documentation is MOST problematic because it:

Answer: Uses a diagnostic term without supporting behavioral observations

Stating 'client appears depressed' without documenting specific behavioral observations (e.g., psychomotor slowing, tearfulness, reported low mood) is clinically vague and legally inadequate.

Which documentation element is MOST critical when a psychologist decides to break confidentiality due to a Tarasoff duty-to-warn situation?

Answer: The specific threat made, identifiable victim, steps taken to warn, and clinical reasoning

Duty-to-warn documentation must include the specific nature of the threat, the identifiable victim, the protective actions taken, and the clinical rationale for the decision.

Under the APA Ethics Code, the recommended minimum retention period for adult client records is:

Answer: 7 years after the last service date, or longer if required by law

APA recommends retaining adult client records for at least 7 years after the last service date, or longer if state law requires, whichever is longer.

A client in an employee assistance program (EAP) asks whether the psychologist has shared their records with their employer. In a properly structured EAP arrangement, the psychologist should inform the client that:

Answer: Only aggregate, non-identifiable utilization data is shared with the employer

Ethically and legally, EAP confidentiality protects individual client records; employers typically receive only aggregate utilization statistics, not identifiable clinical information.

Which of the following scenarios BEST illustrates appropriate use of a release of information (ROI) form?

Answer: A signed, dated ROI specifying recipient, information scope, and expiration is obtained before disclosure

A valid ROI must be signed and dated, identify the specific recipient, define the scope of information to be released, and include an expiration date or condition.

When conducting telehealth sessions, which documentation consideration is UNIQUE compared to in-person practice?

Answer: Client location and technology platform used should be documented for jurisdictional and standard-of-care purposes

Telehealth records should document the client's physical location at the time of service and the platform used, as these affect jurisdictional licensing requirements and standard-of-care determinations.