ABCN Documentation and Record Keeping 3 — Questions and Answers
Question 1: State laws governing the minimum retention period for adult neuropsychological records most commonly require records to be kept for at least:
- 2 years after last contact
- 5 years after last contact
- 7 years after last contact (Correct answer)
- 25 years after last contact
Correct answer: 7 years after last contact
Many states require adult records to be retained for a minimum of 7 years from the date of last contact, though some states vary.
Question 2: When a minor patient turns 18, the minimum record retention period typically begins:
- On the date of the minor's last visit
- On the minor's 18th birthday (Correct answer)
- Three years after the final evaluation
- At the time the parents' consent expires
Correct answer: On the minor's 18th birthday
For minors, many state laws restart the retention clock at the age of majority so records are available into adulthood.
Question 3: A neuropsychologist is closing their private practice. Records of current and recent patients must be:
- Transferred to a storage facility with no patient notification required
- Destroyed immediately to protect confidentiality
- Secured and patients notified so they can retrieve or transfer records (Correct answer)
- Transferred automatically to the nearest hospital system
Correct answer: Secured and patients notified so they can retrieve or transfer records
APA ethics require that upon practice closure, patients must be notified and given reasonable opportunity to transfer their records to another provider.
Question 4: Which element is NOT required in a neuropsychological test report according to standard professional guidelines?
- Reason for referral and relevant history
- The verbatim transcript of every patient statement during testing (Correct answer)
- Behavioral observations during testing
- Summary of findings and diagnostic impressions
Correct answer: The verbatim transcript of every patient statement during testing
Reports require clinically relevant content, but verbatim transcripts of all patient statements are not a standard requirement and may create unnecessary documentation burden.
Question 5: A patient requests that certain information be removed from their neuropsychological record. Under HIPAA, the provider:
- Must delete the information within 10 business days
- May deny the request if the information was compiled for legal proceedings or is accurate and necessary (Correct answer)
- Must comply if the patient provides written authorization
- Is required to comply with all patient amendment requests without exception
Correct answer: May deny the request if the information was compiled for legal proceedings or is accurate and necessary
HIPAA allows providers to deny amendment requests when the record was created for legal proceedings or is accurate and necessary for care.
Question 6: Documentation of a patient's collateral interviews (e.g., with family members) should:
- Be kept entirely separate from the clinical record and never referenced in the report
- Clearly identify the source, date, and nature of the information obtained (Correct answer)
- Attribute all collateral information to the patient to simplify record keeping
- Be omitted from reports to protect third-party confidentiality
Correct answer: Clearly identify the source, date, and nature of the information obtained
Collateral sources must be clearly documented with identification, date, and content to ensure transparency and accuracy of the evaluation record.
Question 7: When a neuropsychologist uses a score reporting service or automated interpretation software, they are ethically responsible for:
- Accepting all automated interpretations verbatim as clinically valid
- Reviewing and clinically integrating the automated output using their own professional judgment (Correct answer)
- Citing the software as the primary author of the report
- Avoiding disclosure to the patient that any software was used
Correct answer: Reviewing and clinically integrating the automated output using their own professional judgment
Psychologists must apply independent professional judgment to automated interpretations and cannot delegate clinical responsibility to software.
ABCN Documentation and Record Keeping 3
State laws governing the minimum retention period for adult neuropsychological records most commonly require records to be kept for at least: