CLEE Record Keeping and Documentation 1 — Questions and Answers
Question 1: Under California law, how long must a licensed therapist retain adult client records after the last date of service?
- 3 years
- 5 years
- 7 years (Correct answer)
- 10 years
Correct answer: 7 years
California law requires adult mental health records to be retained for at least 7 years from the date of last service.
Question 2: For minor clients in California, mental health records must be retained until the minor reaches age 18 or for how long, whichever is longer?
- 3 years after last service
- 5 years after last service
- 7 years after last service (Correct answer)
- 10 years after last service
Correct answer: 7 years after last service
Records for minors must be kept until the minor turns 18 or for 7 years from the last date of service, whichever period is longer.
Question 3: Which of the following must be documented in a client's treatment record according to California ethical and legal standards?
- Only formal psychological test results
- Progress notes, treatment plans, informed consent, and significant clinical decisions (Correct answer)
- Only billing and insurance information
- Only session dates and fees charged
Correct answer: Progress notes, treatment plans, informed consent, and significant clinical decisions
Comprehensive clinical records must include progress notes, treatment plans, informed consent, assessments, and documentation of significant clinical decisions.
Question 4: A therapist is closing their private practice. What is their ethical obligation regarding client records?
- Records can be destroyed since the practice is closing
- Ensure records are transferred or stored in a way that preserves client access and confidentiality (Correct answer)
- Turn all records over to the California BBS for storage
- Notify clients verbally but no written transfer plan is needed
Correct answer: Ensure records are transferred or stored in a way that preserves client access and confidentiality
When closing a practice, therapists must make arrangements for proper record storage or transfer that maintains confidentiality and client access rights.
Question 5: Under California law, a patient's right to access their own mental health records is governed by:
- The Tarasoff Act only
- HIPAA and California Health and Safety Code §123111 (Correct answer)
- The BBS licensing statutes exclusively
- The Welfare and Institutions Code for all clients
Correct answer: HIPAA and California Health and Safety Code §123111
Both HIPAA and California Health and Safety Code §123111 establish patients' rights to access and inspect their own health records.
Question 6: A therapist may withhold a client's records if:
- The client has an outstanding balance for services
- Disclosure would cause substantial harm to the client or others, as documented (Correct answer)
- The therapist determines the client does not need the records
- The records are more than 5 years old
Correct answer: Disclosure would cause substantial harm to the client or others, as documented
California Health and Safety Code §123115 permits withholding records if the treating provider documents that access would cause substantial harm to the patient or a third party.
CLEE Record Keeping and Documentation 1
Under California law, how long must a licensed therapist retain adult client records after the last date of service?