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

When records are subpoenaed, the counselor must consult with an attorney and respond to the legal process appropriately. A subpoena is a legal order and destroying records subject to a subpoena is illegal.

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

Under HIPAA, psychotherapy notes are defined as a counselor's private notes containing their analysis, impressions, and hypotheses. These notes are kept separately from the general record and receive enhanced privacy protections.

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

HIPAA gives clients the right to request amendments to their records, but providers may deny the request in certain circumstances. If denied, the provider must give a written explanation and allow the client to submit a statement of disagreement.

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

Supervision records and case consultation notes are distinct from client clinical records. They should be kept separately and are generally not part of the client's record subject to client 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

HIPAA's Breach Notification Rule requires covered entities to notify affected individuals, HHS, and for large breaches prominent media outlets within specified timeframes following a breach of unsecured protected health information.

OLERE - Oklahoma Legal and Ethical Responsibilities Exam Practice Test

OLERE - Oklahoma Legal and Ethical Responsibilities Exam Practice Test

OLERE Clinical Record Keeping 3