Clinical Documentation & Records Flashcards
7 cards from real ACT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Clinical Documentation & Records flashcards as text
An ACT therapist leaves a group practice and transfers client records to the new provider. Which action is required under HIPAA?
Answer: A written Notice of Privacy Practices update and, where required, client authorization
Transferring records between providers requires a valid client authorization or must meet a HIPAA treatment exception, plus clients should be informed via updated privacy practices.
An ACT clinician stores session notes in a cloud-based EHR. Which safeguard is required under HIPAA's Security Rule?
Answer: A Business Associate Agreement (BAA) with the EHR vendor
Any third-party vendor that handles protected health information must sign a Business Associate Agreement, which outlines their HIPAA compliance obligations.
When documenting a client's progress using the AAQ-II (Acceptance and Action Questionnaire), the clinician should:
Answer: Include baseline score, current score, score change, and clinical interpretation of psychological flexibility
Standardized measures like the AAQ-II should be documented with scores across time, score change interpretation, and how the data informs ongoing ACT case conceptualization.
A court subpoenas an ACT client's therapy records. The correct first step for the clinician is to:
Answer: Consult with legal counsel and notify the client before releasing records unless prohibited
Upon receiving a subpoena, the clinician should consult legal counsel, notify the client (unless legally prohibited), and assert privilege if appropriate before releasing any records.
In ACT case conceptualization documented in a clinical record, 'experiential avoidance' should be described in terms of:
Answer: Observable avoidance behaviors and the psychological functions they serve in maintaining suffering
Documenting experiential avoidance requires specific examples of avoidance behaviors and a functional analysis showing how they maintain or worsen the client's difficulties.
Which scenario represents a mandatory reporting obligation that overrides confidentiality and must be documented in the clinical record?
Answer: A client discloses current abuse of a child they are caring for
Disclosure of current child abuse triggers mandatory reporting obligations in all U.S. states, and the report made, along with the clinical basis for concern, must be documented in the record.
When a client terminates ACT therapy abruptly without notice, what documentation should the clinician complete?
Answer: A termination note documenting the clinical status, outreach attempts, risk considerations, and recommendations for follow-up care
Unilateral termination requires a clinical termination note addressing the client's status, any risk factors, documented outreach attempts, and referral recommendations to protect against abandonment liability.