LPCC Documentation and Record Keeping 2

Question 1

A client requests a copy of their therapy records. Under HIPAA, the counselor must provide access within how many days?

Accepted Answer

30 days, with one 30-day extension if needed

Answer

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?

Accepted Answer

Counselor's personal reactions to the client

Answer

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:

Accepted Answer

Consult with an attorney and notify the client before releasing records

Answer

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:

Accepted Answer

They are stored separately and require specific authorization for release

Answer

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:

Accepted Answer

Pejorative labels can harm the client if records are accessed and reflect bias

Answer

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.

(LPCC) Licensed Professional Clinical Counselors Certification Practice Test

(LPCC) Licensed Professional Clinical Counselors Certification Practice Test

LPCC Documentation and Record Keeping 2