HSP Documentation & Record Keeping 2

Question 1

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

Accepted Answer

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

Answer

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.

Question 2

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

Accepted Answer

Consult with legal counsel and notify the client before releasing records

Answer

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.

Question 3

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

Accepted Answer

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

Answer

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.

Question 4

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

Accepted Answer

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

Answer

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.

Question 5

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:

Accepted Answer

Legally and ethically appropriate if destruction followed proper procedures

Answer

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

(HSP) Certified Health Service Psychologist Practice Test

(HSP) Certified Health Service Psychologist Practice Test

HSP Documentation & Record Keeping 2