Documentation & Record Keeping Flashcards

Under HIPAA, the minimum necessary standard requires covered entities to:

Answer: Limit PHI disclosures to the minimum needed to accomplish the intended purpose

The minimum necessary standard requires that covered entities limit the PHI they use, disclose, or request to the minimum amount needed to accomplish the intended purpose.

A psychologist's treatment notes are subpoenaed in a custody dispute. The BEST initial course of action is to:

Answer: Consult with legal counsel and notify the client before releasing records

When records are subpoenaed, the psychologist should consult with legal counsel and notify the client so the client can seek their own legal remedy before disclosure.

Which of the following is considered a 'psychotherapy note' under HIPAA and receives additional privacy protections?

Answer: The psychologist's private process notes kept separate from the medical record

HIPAA defines psychotherapy notes as notes recorded in any medium by a mental health professional documenting private conversations, kept separate from the rest of the medical record.

When documenting a client's suicide risk assessment, a psychologist should MOST importantly record:

Answer: The clinical reasoning, risk and protective factors assessed, and the safety plan

Risk assessment documentation must capture the clinical reasoning process, risk and protective factors weighed, and the resulting safety plan to demonstrate defensible clinical decision-making.

A former client requests all records dating back 12 years. The psychologist's state law requires retention of adult records for 7 years. The psychologist has already destroyed records older than 7 years. This is:

Answer: Legally and ethically appropriate if destruction followed proper procedures

Destroying records in accordance with applicable state retention laws and proper destruction procedures is both legally and ethically appropriate.

Which documentation practice BEST protects a psychologist in a malpractice claim involving a missed diagnosis?

Answer: Contemporaneous documentation of the differential diagnosis process and clinical reasoning

Contemporaneous notes showing the differential diagnosis process and clinical reasoning demonstrate that the psychologist exercised appropriate professional judgment at the time of treatment.

A psychologist working in a group practice wants to share a client's record with a colleague for peer consultation. The APPROPRIATE approach under HIPAA is to:

Answer: Use de-identified information when possible; if not, use the minimum necessary PHI

Peer consultation for treatment purposes is permitted under HIPAA's treatment exception, but the minimum necessary standard still applies, so de-identified information should be used when feasible.