Documentation and Record Keeping Flashcards
7 cards from real CBHT 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 and Record Keeping flashcards as text
Which of the following circumstances requires a BHT to break confidentiality?
Answer: A client discloses a plan to harm a specific person
Duty to warn requires clinicians to break confidentiality when a client makes a credible threat of serious harm to an identifiable third party.
In electronic health records (EHR), what does an 'audit trail' provide?
Answer: A log of who accessed, modified, or viewed a record and when
An audit trail in an EHR automatically tracks all access and changes to a record, supporting accountability and HIPAA compliance.
Which of the following is NOT an appropriate reason to access a client's behavioral health record?
Answer: To satisfy personal curiosity about the client's history
Accessing records out of personal curiosity, without a clinical need, is a HIPAA violation and an ethical breach known as 'snooping.'
When documenting a client's progress toward treatment goals, BHTs should use language that is:
Answer: Specific, behavioral, and measurable to reflect actual progress
Effective treatment progress documentation must be specific, behavioral, and measurable to accurately reflect the client's status and support ongoing care decisions.
A client's release of information form expires. What should a BHT do before sharing records with a third party?
Answer: Obtain a new, valid release of information form signed by the client
Releases of information have expiration dates; once expired, a new signed release must be obtained before any protected health information is shared.
Which of the following best defines 'minimum necessary standard' under HIPAA?
Answer: Only disclose the minimum amount of PHI needed to accomplish the intended purpose
The minimum necessary standard requires that only the least amount of PHI needed for a specific purpose be used or disclosed, protecting client privacy.
Which section of a DAP progress note contains the clinician's interpretation of the client's status?
Answer: Assessment
In DAP notes, the Assessment section contains the clinician's professional interpretation or analysis of the information recorded in the Data section.