CDS Documentation & Record Keeping 2

Question 1

Under HIPAA, a disability specialist must obtain written authorization before disclosing a client's protected health information (PHI) to which entity?

Accepted Answer

A third-party life insurance company

Answer

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:

Accepted Answer

Functional and activity-based to describe real-world impact

Answer

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:

Accepted Answer

Provide the client an opportunity to submit a written correction or amendment

Answer

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?

Accepted Answer

5 years after case closure

Answer

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:

Accepted Answer

Specialist's professional opinion about the client's personality

Answer

Legally defensible notes document observable facts and interventions; subjective personality judgments are inappropriate and expose the agency to liability.

(CDS) Certified Disability Specialist Practice Test

(CDS) Certified Disability Specialist Practice Test

CDS Documentation & Record Keeping 2