ABCN Documentation and Record Keeping 2

Question 1

Under HIPAA, a covered entity must provide a patient with access to their medical records within how many days of a request?

Accepted Answer

30 days

Answer

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?

Accepted Answer

Writing contemporaneous, objective notes immediately after each session

Answer

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:

Accepted Answer

Add an addendum to the record noting the correction and date

Answer

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:

Accepted Answer

Released to qualified professionals upon appropriate authorization

Answer

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:

Accepted Answer

Consult legal counsel and, where possible, notify the patient before releasing records

Answer

Clinicians should seek legal guidance and attempt to notify the patient, as some subpoenas may be quashed or limited by privilege.

(ABCN) American Board of Clinical Neuropsychology Practice Test