Question 1

The Health Insurance Portability and Accountability Act (HIPAA) requires that:

Accepted Answer

A)  counselors give clients a clear written explanation of how they use, keep, and disclose their health care information. 
B)  clients have access to their records. 
C)  a written process exists for clients to request amendments to their records. 
D)  a written history of most disclosures of client information be available to clients. 
E)  all of the above. E

Question 2

Which of the following statements is most appropriate regarding clinical case notes?

Accepted Answer

A)  counselors should not take clinical case notes if they are worried about the notes being subpoenaed or later being seen by the client or anyone else. 
B)  counselors should take the clinical notes they need in order to function effectively as professionals. 
C)  it is reasonable to assume that clinical case notes will not be read by anyone other than the counselor who wrote them. 
D)  writing illegible case notes is a protection against being called upon to reveal sensitive information pursuant to a subpoena. 
E)  if clinical case notes are kept at the home of the counselor, they cannot be subpoenaed. B

Question 3

The Family Educational Rights and Privacy Act of 1974 (FERPA), which is sometimes referred to as the "Buckley Amendment," affects all:

Accepted Answer

A)  community mental health centers in the United States. 
B)  public educational institutions. 
C)  private or parochial educational institutions. 
D)  public hospitals. 
E)  private hospitals. B

Question 4

Legal principles view the contents of a client's counseling records as belonging to:

Accepted Answer

A)  the client's counselor. 
B)  the agency where the counseling took place. 
C)  the client. 
D)  the court that has requested the records. 
E)  the insurance company that paid for the counseling sessions.

Question 5

Per State v. Brown, 1985 and State v. Magnuson, 1984, ??___________ can be used against clients in criminal investigations and is not protected by the Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1972.

Accepted Answer

A)  clinical case notes 
B)  counselor direct observations 
C)  information gathered through psychological assessments 
D)  psychiatric medication records 
E)  direct quotations from counseling sessions

Question 6

Generally, counselors create clinical case notes:

Accepted Answer

A)  to protect themselves in the event they are later sued. 
B)  for their own use, so that they may be effective counselors. 
C)  for insurance companies who reimburse clients for the cost of mental health services. 
D)  to keep up with whether the client attended sessions on particular days and whether the client paid for the sessions that were rendered. 
E)  so that they may reflect upon their counseling sessions and improve their skills.

Question 7

If a subpoena for the counseling records of a client is received, a counselor who works in a mental health agency should:

Accepted Answer

A)  ask his or her supervisor to obtain a legal opinion as to whether the records should be copied for the attorney who has issued the subpoena. 
B)  immediately turn the records over to the attorney who has issued the subpoena. 
C)  call the attorney who has issued the subpoena and request that the subpoena be withdrawn. 
D)  consult with a counselor colleague before deciding how to respond. 
E)  hire an attorney in private practice and ask the attorney to tell the counselor whether the records should be copied for the attorney who has issued the subpoena.

Question 8

In compliance with the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1972, federally funded substance abuse programs can disclose client records under the following circumstances:

Accepted Answer

A)  when the client gives written consent. 
B)  in the event of a medical emergency. 
C)  for an audit or evaluation. 
D)  to avert substantial risk of death or serious bodily harm if a court order is secured. 
E)  All of the above.

Question 9

HIPAA rules state that if clients are first informed and given an opportunity to orally object:

Accepted Answer

A)  psychotherapy notes created by the counselor may be transferred to insurance companies. 
B)  insurance companies may pay counselors directly for the services they render to clients. 
C)  their records may be transferred to another mental health professional. 
D)  their records may be destroyed at the end of the counseling relationship. 
E)  counselors may give health care information to family members or others assisting in the client's care.

Question 10

The three major types of records that counselors keep are:

Accepted Answer

A)  clinical case notes, financial, and treatment plan. 
B)  phone and other correspondence, clinical case notes, and treatment plan. 
C)  administrative, financial, and clinical case notes. 
D)  recordings, clinical case notes, and administrative. 
E)  typed, hand-written, and audio.

Question 11

When documenting for self-protection, counselors should not include:

Accepted Answer

A)  exact times and dates. 
B)  counselors' thoughts, diagnoses, and conclusions. 
C)  direct quotations and statements. 
D)  a great deal of detail. 
E)  factual information.

Question 12

Keeping good records can benefit both counselors and clients in the following ways EXCEPT:

Accepted Answer

A)  proving that the counselor is not impaired or suffering from burnout. 
B)  providing continuity of care if a client is transferred to another provider. 
C)  measuring progress in treatment. 
D)  creating an accurate history of diagnosis, treatment, and recovery. 
E)  offering self-protection for counselors.

Question 13

When documenting for self-protection:

Accepted Answer

A)  documentation should be relatively vague so as not to reveal too much information. 
B)  as much detail as possible (e.g., dates, times of events, and exact words spoken) should be included. 
C)  in the event a counselor realizes that documentation should have been occurring sooner, the counselor should back-date the documentation rather than write a summary of what has happened up to that point in time. 
D)  counselors document to avoid responsibility for clinical decisions that were made or actions that were taken. 
E)  counselors should avoid including information related to disagreements they have had with a client.

Question 14

Subpoenas are used:

Accepted Answer

A)  to obtain copies of records. 
B)  to cause potential witnesses to testify at a deposition, hearing, or trial. 
C)  to ask potential witnesses to respond in writing to written questions. 
D)  to require witnesses to appear at a deposition, hearing, or trail and to bring their records with them. 
E)  all of the above.

Question 15

When counselor trainees make audiotapes or videotapes of counseling sessions for supervision purposes:

Accepted Answer

A)  trainees must retrieve the tapes after the supervisors have reviewed them and then erase the tapes. 
B)  supervisors must handle the tapes appropriately during the time the tapes are in the supervisors' possession. 
C)  supervisors should return tapes to trainees after the tapes have been reviewed. 
D)  the tapes should be labeled simply, in a manner that does not bring attention to the fact that the tapes are confidential records. 
E)  all of the above.

Exam 6: Records and Subpoenas