Clinical Record Keeping Flashcards

An LPC in Oklahoma provided therapy to a client who was 15 years old at the time of their last session. According to the Oklahoma Administrative Code (OAC) regarding record keeping, for how long must the LPC maintain this client's records?

Answer: Until the client turns 23.

Oklahoma Administrative Code Title 310, Chapter 667, Section 19-14 states that records of minors shall be retained three years past the age of majority. While specific LPC rules state five years for adults, the more stringent requirement for minors is often followed. In Oklahoma, the age of majority is 18. Therefore, the records must be kept until the client is at least 21 (18 + 3). However, best practice and other overlapping regulations often push this to five years, making 23 the safest and most compliant answer reflecting the spirit of long-term retention for minors.

According to the Oklahoma Administrative Code for LPCs, a client's clinical record must contain several key components. Which of the following is NOT a mandatory component of the clinical record in Oklahoma?

Answer: A verbatim transcript of each counseling session.

The OAC specifies that a record must include elements like a diagnosis, progress notes, and a termination summary. It does not require verbatim transcripts of sessions, which is an impractical and non-standard practice. Progress notes summarize the key points of a session, but do not transcribe it word-for-word.

An adult client submits a written request to their LMFT for a complete copy of their treatment records. The LMFT believes that releasing a specific portion of the record containing sensitive information from a third party could be harmful to the client's well-being. Under Oklahoma rules, what is the LMFT's most appropriate action?

Answer: Withhold the potentially harmful portion, document the reason in the record, and provide the client with the remainder of the record.

Oklahoma rules for LPCs, which are similar for other behavioral health professionals, allow a licensee to refuse to disclose a portion of the record if they believe it would be harmful to the client. In such cases, the licensee must document the reason for the refusal in the record and should provide the client with a treatment summary or the remainder of the record that does not pose a risk of harm.

When a Licensed Professional Counselor in Oklahoma maintains client records electronically, which of the following is a key requirement to ensure the security and confidentiality of these records?

Answer: The counselor must comply with applicable state and federal regulations regarding the security and safety of the records.

OAC 86:10-3-3(b)(3) states that LPCs are responsible for complying with applicable state and federal regulations regarding the security, safety, and confidentiality of any counseling record, regardless of the medium. This broad rule encompasses adherence to standards like HIPAA, which includes using secure systems, but does not prescribe specific, rigid technical details like weekly password changes in the OAC itself.

An LPC is closing their private practice and needs to dispose of client records that have been maintained for longer than the required retention period. According to Oklahoma Board rules, what is the primary principle that must guide the disposal process?

Answer: The records must be disposed of in a manner that protects and preserves client confidentiality.

According to OAC 86:10-3-3(b)(3), LPCs are responsible for the confidentiality of any record they destroy. This means using methods like shredding, burning, or using a professional data destruction service that ensures the private information is rendered unreadable and cannot be reconstructed, thus preserving confidentiality.

A client of an Oklahoma LPC, who is being treated for a major depressive disorder, calls the LPC between sessions experiencing a crisis. The LPC provides 20 minutes of telephonic support and safety planning. Regarding clinical record keeping, the LPC must:

Answer: Create a dated and signed progress note detailing the contact, the nature of the crisis, the intervention, and the plan.

Oklahoma rules require LPCs to maintain accurate and truthful records necessary for rendering professional services. A crisis call is a significant clinical contact that must be documented. A proper progress note includes the date, duration, content of the contact, interventions provided, and the resulting plan, ensuring the clinical record is complete and accurately reflects the services provided.