LPCC Documentation and Record Keeping 2 — Questions and Answers
Question 1: A client requests a copy of their therapy records. Under HIPAA, the counselor must provide access within how many days?
- 30 days, with one 30-day extension if needed (Correct answer)
- 60 days, no extension allowed
- 10 business days
- 90 days for mental health records
Correct answer: 30 days, with one 30-day extension if needed
HIPAA requires covered entities to provide access to records within 30 days, with one possible 30-day extension if the reason is communicated in writing.
Question 2: Which element is typically NOT included in a treatment plan document?
- Long-term therapeutic goals
- Counselor's personal reactions to the client (Correct answer)
- Identified presenting problems
- Planned interventions and modalities
Correct answer: Counselor's personal reactions to the client
Treatment plans document client goals, problems, and interventions; the counselor's personal emotional reactions are not appropriate treatment plan content.
Question 3: When a counselor receives a subpoena for client records, the most appropriate initial step is to:
- Immediately release all records to comply with the court
- Consult with an attorney and notify the client before releasing records (Correct answer)
- Destroy sensitive portions of the record
- Release only the treatment plan but withhold session notes
Correct answer: Consult with an attorney and notify the client before releasing records
Upon receiving a subpoena, counselors should consult legal counsel and notify the client to allow the client to assert privilege before any records are released.
Question 4: Psychotherapy notes under HIPAA receive additional protections compared to standard medical records because:
- They are stored separately and require specific authorization for release (Correct answer)
- They are owned by the client, not the provider
- They must be destroyed after 7 years
- They can only be accessed by psychiatrists
Correct answer: They are stored separately and require specific authorization for release
HIPAA defines psychotherapy notes as notes kept separate from the medical record, requiring specific client authorization for most disclosures beyond treatment.
Question 5: A counselor documents that a client is 'resistant' and 'manipulative' in session notes. This practice is problematic primarily because:
- Such terms are not billable diagnoses
- Pejorative labels can harm the client if records are accessed and reflect bias (Correct answer)
- Resistance cannot be documented without supervisor approval
- State boards prohibit adjective use in records
Correct answer: Pejorative labels can harm the client if records are accessed and reflect bias
Using pejorative labels in records reflects potential bias, can harm the therapeutic relationship if disclosed, and does not meet the standard of objective, behaviorally specific documentation.
Question 6: Which scenario best demonstrates appropriate use of a DAP progress note format?
- Data: client reports anxiety; Assessment: GAD confirmed; Plan: continue CBT (Correct answer)
- Data: client seems sad; Assessment: client needs support; Plan: be supportive next session
- Data: client is difficult; Assessment: poor prognosis; Plan: refer out soon
- Data: client arrived late; Assessment: avoidance; Plan: no changes needed
Correct answer: Data: client reports anxiety; Assessment: GAD confirmed; Plan: continue CBT
A proper DAP note documents observable data, a clinical assessment linked to treatment, and a specific evidence-based plan.
Question 7: A counselor accidentally sends a client's intake form to the wrong fax number. Under HIPAA, this constitutes a:
- Breach requiring assessment and likely notification (Correct answer)
- Minor error that requires no follow-up if discovered quickly
- Violation only if the recipient reads the document
- Non-event if the information is not sensitive
Correct answer: Breach requiring assessment and likely notification
Unauthorized disclosure of protected health information requires a breach risk assessment and notification to the client if the risk threshold is met.
LPCC Documentation and Record Keeping 2
A client requests a copy of their therapy records.
Under HIPAA, the counselor must provide access within how many days?