CDS Documentation & Record Keeping 2 — Questions and Answers
Question 1: Under HIPAA, a disability specialist must obtain written authorization before disclosing a client's protected health information (PHI) to which entity?
- A treating physician directly involved in care
- An employer requesting disability verification for accommodation
- A state vocational rehabilitation agency with a signed ROI
- A third-party life insurance company (Correct answer)
Correct answer: A third-party life insurance company
Life insurance companies are not covered entities and require explicit written HIPAA authorization before receiving PHI.
Question 2: When documenting a client's functional limitations, the CDS should use language that is:
- Diagnostic and clinical to satisfy medical reviewers
- Functional and activity-based to describe real-world impact (Correct answer)
- Vague to avoid limiting the client's options
- Identical to the physician's chart notes
Correct answer: Functional and activity-based to describe real-world impact
Functional, activity-based language describes how a disability affects daily tasks and is most useful for accommodation and benefits determinations.
Question 3: A client disputes the accuracy of information in their case file. Under most disability service regulations, the specialist must:
- Delete the disputed record immediately
- Provide the client an opportunity to submit a written correction or amendment (Correct answer)
- Seal the file until a hearing officer reviews it
- Transfer the file to legal counsel
Correct answer: Provide the client an opportunity to submit a written correction or amendment
Clients generally have the right to request corrections or amendments to their records, which must be documented even if the agency disagrees.
Question 4: Which retention period is most commonly required for vocational rehabilitation case records at the federal level?
- 3 years after case closure
- 5 years after case closure (Correct answer)
- 7 years after case closure
- 10 years after case closure
Correct answer: 5 years after case closure
Federal VR regulations generally require retention of case records for a minimum of 5 years after case closure.
Question 5: A progress note is considered legally defensible when it includes all of the following EXCEPT:
- Date and time of service
- Specialist's professional opinion about the client's personality (Correct answer)
- Observable client behaviors and statements
- Specialist's signature and credentials
Correct answer: Specialist's professional opinion about the client's personality
Legally defensible notes document observable facts and interventions; subjective personality judgments are inappropriate and expose the agency to liability.
Question 6: An Individualized Plan for Employment (IPE) must be documented with input from the client primarily to:
- Meet the agency's billing cycle requirements
- Satisfy the client's self-determination rights under the Rehabilitation Act (Correct answer)
- Allow the counselor to set goals without client interference
- Reduce the frequency of required progress reviews
Correct answer: Satisfy the client's self-determination rights under the Rehabilitation Act
The Rehabilitation Act mandates client involvement in IPE development as an expression of informed choice and self-determination.
Question 7: Which documentation element best demonstrates that a disability specialist obtained informed consent before initiating services?
- A verbal confirmation recorded in the case notes
- A signed consent form that describes services, risks, and the right to withdraw (Correct answer)
- The agency intake form signed at the front desk
- A supervisor co-signature on the service plan
Correct answer: A signed consent form that describes services, risks, and the right to withdraw
Informed consent requires a signed document that clearly describes the services, potential risks, and the client's right to withdraw at any time.
CDS Documentation & Record Keeping 2
Under HIPAA, a disability specialist must obtain written authorization before disclosing a client's protected health information (PHI) to which entity?