OLERE - Oklahoma Legal and Ethical Responsibilities Clinical Record Keeping Questions and Answers

Question 1

An LPC in Oklahoma provided therapy to a client who was 15 years old at the time of their last session.
According to the Oklahoma Administrative Code (OAC) regarding record keeping, for how long must the LPC maintain this client's records?

Accepted Answer

Until the client turns 23.

Answer

For five years from the date of the last session.

Answer

Indefinitely, because the client was a minor.

Answer

Until the client turns 21.

Question 2

According to the Oklahoma Administrative Code for LPCs, a client's clinical record must contain several key components. Which of the following is NOT a mandatory component of the clinical record in Oklahoma?

Accepted Answer

A verbatim transcript of each counseling session.

Answer

A termination summary.

Answer

The client's presenting problem(s) and a diagnosis or clinical impression.

Answer

Dated and signed progress notes for each contact.

Question 3

An adult client submits a written request to their LMFT for a complete copy of their treatment records. The LMFT believes that releasing a specific portion of the record containing sensitive information from a third party could be harmful to the client's well-being. Under Oklahoma rules, what is the LMFT's most appropriate action?

Accepted Answer

Withhold the potentially harmful portion, document the reason in the record, and provide the client with the remainder of the record.

Answer

Refuse the entire request, stating that records are the property of the therapist.

Answer

Immediately provide the complete record to the client without question.

Answer

Inform the client that they must obtain a court order to see their records.

Question 4

When a Licensed Professional Counselor in Oklahoma maintains client records electronically, which of the following is a key requirement to ensure the security and confidentiality of these records?

Accepted Answer

The counselor must comply with applicable state and federal regulations regarding the security and safety of the records.

Answer

All electronic records must be printed out and stored in a physical file annually.

Answer

The electronic system must be registered with the Oklahoma Board of Behavioral Health.

Answer

Records must be password-protected with a new password generated weekly.

Question 5

An LPC is closing their private practice and needs to dispose of client records that have been maintained for longer than the required retention period. According to Oklahoma Board rules, what is the primary principle that must guide the disposal process?

Accepted Answer

The records must be disposed of in a manner that protects and preserves client confidentiality.

Answer

The disposal method must be approved in writing by each former client.

Answer

The records must be offered to a professional archival service before destruction.

Answer

The disposal must be witnessed and signed off on by another licensed professional.

Question 6

A client of an Oklahoma LPC, who is being treated for a major depressive disorder, calls the LPC between sessions experiencing a crisis. The LPC provides 20 minutes of telephonic support and safety planning. Regarding clinical record keeping, the LPC must:

Accepted Answer

Create a dated and signed progress note detailing the contact, the nature of the crisis, the intervention, and the plan.

Answer

Wait until the next scheduled session to discuss the call and document it then.

Answer

Only document the call if it results in a referral to a higher level of care.

Answer

Send the client a text message summary of the call instead of making a formal record entry.

An LPC in Oklahoma provided therapy to a client who was 15 years old at the time of their last session.According to the Oklahoma Administrative Code (OAC) regarding record keeping, for how long must the LPC maintain this client's records?

An LPC in Oklahoma provided therapy to a client who was 15 years old at the time of their last session.
According to the Oklahoma Administrative Code (OAC) regarding record keeping, for how long must the LPC maintain this client's records?