Documentation & Record Management Flashcards
7 cards from real CAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Record Management flashcards as text
A CAA coach is switching from paper to digital records. Which factor is MOST important when selecting a digital platform for client documentation?
Answer: HIPAA-compliant encryption and access controls
HIPAA-compliant encryption and access controls protect confidential client information and are the top priority when selecting a digital documentation platform.
Which element should always appear on a coaching session note to ensure clarity and accountability?
Answer: Date of session, goals discussed, and action steps agreed upon
Session notes should at minimum capture the date, goals addressed, and action steps to create a clear record of progress and commitments.
A client requests their complete coaching file. Under ethical best practices, the coach should:
Answer: Share the records in a timely manner as the client owns their own data
Clients have the right to access their own records, and ethical coaching practice requires timely provision of that information upon request.
How long should a certified ADHD coach typically retain client records after the coaching relationship ends?
Answer: At least 7 years, or longer if state law requires
A minimum of 7 years is a widely recommended retention period, though coaches must also comply with applicable state laws that may require longer retention.
Which practice BEST protects against unauthorized access to electronic client records?
Answer: Using unique strong passwords and two-factor authentication
Strong, unique passwords combined with two-factor authentication significantly reduce the risk of unauthorized access to sensitive electronic records.
A coach notices a discrepancy between what a client said in session and what was documented in a previous note. The BEST course of action is to:
Answer: Discuss the discrepancy with the client and document the clarification
Discussing the discrepancy with the client and documenting the outcome preserves accuracy and transparency without altering the original record.
Which of the following is an example of a breach of documentation confidentiality?
Answer: Leaving printed session notes visible on a shared office desk
Leaving identifying client notes visible in a shared space violates confidentiality by exposing private information to unauthorized individuals.