OLERE Clinical Record Keeping 3

Question 1

A counselor's clinical notes for a deceased client are subpoenaed in a wrongful death lawsuit. The counselor should:

Accepted Answer

Consult with an attorney and respond appropriately to the legal process

Answer

Destroy the records to protect the deceased client's privacy

Answer

Release records only to the deceased client's estate attorney

Answer

Refuse to comply because the client can no longer consent

Question 2

Which of the following best describes the content that should appear in a psychotherapy note under HIPAA, as distinct from the general medical record?

Accepted Answer

The counselor's analysis, session impressions, and hypotheses kept separately from the main record

Answer

Diagnosis, treatment summary, and billing information

Answer

Session start and stop times, medications, and treatment plan

Answer

Progress toward treatment goals only

Question 3

A client in Oklahoma requests that their counselor amend a clinical record that the client believes is inaccurate. Under HIPAA, the counselor:

Accepted Answer

May deny the amendment request but must provide the client with a written denial and the right to submit a statement of disagreement

Answer

Must make all amendments requested by the client

Answer

Can ignore the request as records are the counselor's professional property

Answer

Must delete the disputed entry and replace it with the client's preferred version

Question 4

A supervising LPC-Supervisor in Oklahoma reviews clinical notes written by their supervisee. Regarding the supervisory record, the supervisor should:

Accepted Answer

Keep supervision notes completely separate from the client record

Answer

Include supervision notes in the client's clinical record for transparency

Answer

Destroy supervision notes after each session to protect confidentiality

Answer

Share supervision notes with clients upon request as part of their record access rights

Question 5

An Oklahoma counselor's practice is hit by a cyberattack that results in a breach of electronic client records. Under HIPAA, the counselor must:

Accepted Answer

Notify affected clients, HHS, and potentially the media within required timeframes

Answer

Keep the breach confidential to protect clients from embarrassment

Answer

Wait to assess the full damage before deciding whether notification is required

Answer

Only notify clients who specifically request information about the breach

Question 6

A counselor in Oklahoma transfers their paper client records to electronic format. Which of the following is essential to this process?

Accepted Answer

Ensuring the electronic records meet HIPAA security requirements and maintaining paper originals for the required retention period

Answer

Immediately destroying all paper originals after scanning

Answer

Notifying clients of the format change and obtaining new consents for all records

Answer

Applying for a HIPAA exemption due to the small size of the practice