HSP Documentation & Record Keeping 4

Question 1

A psychologist is closing their private practice. Regarding client records, they are ethically obligated to:

Accepted Answer

Notify clients, arrange for record storage or transfer, and ensure continued access

Answer

When closing a practice, APA ethics require notifying clients, making arrangements for proper record storage or transfer, and ensuring clients can access their records.

Question 2

A psychologist's progress note states: 'Client appears depressed.' This documentation is MOST problematic because it:

Accepted Answer

Uses a diagnostic term without supporting behavioral observations

Answer

Stating 'client appears depressed' without documenting specific behavioral observations (e.g., psychomotor slowing, tearfulness, reported low mood) is clinically vague and legally inadequate.

Question 3

Which documentation element is MOST critical when a psychologist decides to break confidentiality due to a Tarasoff duty-to-warn situation?

Accepted Answer

The specific threat made, identifiable victim, steps taken to warn, and clinical reasoning

Answer

Duty-to-warn documentation must include the specific nature of the threat, the identifiable victim, the protective actions taken, and the clinical rationale for the decision.

Question 4

Under the APA Ethics Code, the recommended minimum retention period for adult client records is:

Accepted Answer

7 years after the last service date, or longer if required by law

Answer

APA recommends retaining adult client records for at least 7 years after the last service date, or longer if state law requires, whichever is longer.

Question 5

A client in an employee assistance program (EAP) asks whether the psychologist has shared their records with their employer. In a properly structured EAP arrangement, the psychologist should inform the client that:

Accepted Answer

Only aggregate, non-identifiable utilization data is shared with the employer

Answer

Ethically and legally, EAP confidentiality protects individual client records; employers typically receive only aggregate utilization statistics, not identifiable clinical information.

(HSP) Certified Health Service Psychologist Practice Test

(HSP) Certified Health Service Psychologist Practice Test

HSP Documentation & Record Keeping 4