Clinical Record Keeping Flashcards
6 cards from real OLERE practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Clinical Record Keeping flashcards as text
Under Oklahoma law and professional standards, how long must a licensed counselor retain adult client records after the last date of service?
Answer: 7 years
Oklahoma professional standards generally require counselors to retain adult client records for at least 7 years after the last date of service, aligning with common professional and legal standards for mental health records.
Which of the following should NOT be included in a clinical case note under best practice standards?
Answer: The counselor's personal opinions about the client's character
Clinical notes should be objective and professional. Personal opinions about a client's character that are not clinically relevant are inappropriate in clinical records and could harm the client if the records are disclosed.
A counselor discovers an error in a previously completed clinical note. The appropriate way to correct the error is to:
Answer: Draw a single line through the error, note the correction, date and initial it
The correct method for correcting errors in clinical records is to draw a single line through the error, write the correction, and add the date and initials. This maintains the original record while documenting the correction.
A counselor is closing their private practice. What obligation does the counselor have regarding client records?
Answer: Records must be stored securely, clients must be notified, and proper transfer arrangements must be made
When closing a practice, counselors have an ethical and legal obligation to store records securely for the required retention period, notify clients of the closure and how to access their records, and arrange for appropriate transfer or continued storage.
Under HIPAA's minimum necessary standard, an Oklahoma counselor must:
Answer: Disclose only the minimum amount of protected health information necessary to accomplish the intended purpose
HIPAA's minimum necessary standard requires that when disclosing protected health information, providers share only the information that is necessary for the stated purpose, not complete records unless specifically required.
Which of the following is true about the security requirements for electronic clinical records under HIPAA?
Answer: Electronic records require administrative, physical, and technical safeguards
HIPAA's Security Rule requires covered entities to implement administrative, physical, and technical safeguards for electronic protected health information regardless of the size of the practice.