Documentation and Record Keeping Flashcards
7 cards from real LPCC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation and Record Keeping flashcards as text
A client requests a copy of their therapy records. Under HIPAA, the counselor must provide access within how many days?
Answer: 30 days, with one 30-day extension if needed
HIPAA requires covered entities to provide access to records within 30 days, with one possible 30-day extension if the reason is communicated in writing.
Which element is typically NOT included in a treatment plan document?
Answer: Counselor's personal reactions to the client
Treatment plans document client goals, problems, and interventions; the counselor's personal emotional reactions are not appropriate treatment plan content.
When a counselor receives a subpoena for client records, the most appropriate initial step is to:
Answer: Consult with an attorney and notify the client before releasing records
Upon receiving a subpoena, counselors should consult legal counsel and notify the client to allow the client to assert privilege before any records are released.
Psychotherapy notes under HIPAA receive additional protections compared to standard medical records because:
Answer: They are stored separately and require specific authorization for release
HIPAA defines psychotherapy notes as notes kept separate from the medical record, requiring specific client authorization for most disclosures beyond treatment.
A counselor documents that a client is 'resistant' and 'manipulative' in session notes. This practice is problematic primarily because:
Answer: Pejorative labels can harm the client if records are accessed and reflect bias
Using pejorative labels in records reflects potential bias, can harm the therapeutic relationship if disclosed, and does not meet the standard of objective, behaviorally specific documentation.
Which scenario best demonstrates appropriate use of a DAP progress note format?
Answer: Data: client reports anxiety; Assessment: GAD confirmed; Plan: continue CBT
A proper DAP note documents observable data, a clinical assessment linked to treatment, and a specific evidence-based plan.
A counselor accidentally sends a client's intake form to the wrong fax number. Under HIPAA, this constitutes a:
Answer: Breach requiring assessment and likely notification
Unauthorized disclosure of protected health information requires a breach risk assessment and notification to the client if the risk threshold is met.