ABCN Documentation and Record Keeping 2 — Questions and Answers
Question 1: Under HIPAA, a covered entity must provide a patient with access to their medical records within how many days of a request?
- 15 days
- 30 days (Correct answer)
- 60 days
- 90 days
Correct answer: 30 days
HIPAA requires covered entities to provide access to records within 30 days, with a possible 30-day extension if written notice is given.
Question 2: Which documentation practice best protects a neuropsychologist when a patient later disputes the content of a session?
- Relying on session audio recordings alone
- Writing contemporaneous, objective notes immediately after each session (Correct answer)
- Having the patient sign a blank consent form at intake
- Summarizing multiple sessions in a single weekly note
Correct answer: Writing contemporaneous, objective notes immediately after each session
Contemporaneous notes written close in time to the encounter carry the greatest evidentiary weight and reflect accurate recall.
Question 3: A neuropsychologist discovers an error in a previously finalized report. The most appropriate action is to:
- Destroy the original and reissue the corrected report without notation
- Add an addendum to the record noting the correction and date (Correct answer)
- Leave the error uncorrected to avoid drawing attention to it
- Contact the referral source verbally only and make no written record
Correct answer: Add an addendum to the record noting the correction and date
An addendum with the correction date maintains record integrity while transparently documenting the change.
Question 4: When documenting a neuropsychological evaluation, raw test data should be:
- Shared freely with any healthcare provider who requests them
- Withheld from all third parties regardless of consent
- Released to qualified professionals upon appropriate authorization (Correct answer)
- Destroyed after the final report is issued
Correct answer: Released to qualified professionals upon appropriate authorization
APA ethics guidelines allow release of raw test data to qualified professionals when the patient provides written authorization.
Question 5: A court subpoena for a patient's neuropsychological records requires the clinician to:
- Immediately comply and release all records without patient notification
- Consult legal counsel and, where possible, notify the patient before releasing records (Correct answer)
- Refuse on grounds of psychologist-patient privilege in all circumstances
- Permanently seal the records to prevent court access
Correct answer: Consult legal counsel and, where possible, notify the patient before releasing records
Clinicians should seek legal guidance and attempt to notify the patient, as some subpoenas may be quashed or limited by privilege.
Question 6: Which statement about electronic health record (EHR) audit trails is most accurate in neuropsychological practice?
- Audit trails are optional and rarely reviewed
- Audit trails automatically document who accessed, modified, or deleted records and when (Correct answer)
- Audit trails apply only to billing records, not clinical notes
- Clinicians are responsible for manually creating their own audit logs
Correct answer: Audit trails automatically document who accessed, modified, or deleted records and when
EHR systems are required to maintain automatic audit trails that log all access and modifications as part of HIPAA Security Rule compliance.
Question 7: Documentation of informed consent for neuropsychological testing should include:
- Only the patient's signature on a generic consent form
- A description of the evaluation purpose, procedures, limits of confidentiality, and patient acknowledgment (Correct answer)
- The clinician's attestation that consent was assumed based on the referral
- Consent for testing only, with confidentiality discussed verbally
Correct answer: A description of the evaluation purpose, procedures, limits of confidentiality, and patient acknowledgment
Comprehensive informed consent documentation covers the nature of the evaluation, what will be done with results, and any limits to confidentiality.
ABCN Documentation and Record Keeping 2
Under HIPAA, a covered entity must provide a patient with access to their medical records within how many days of a request?