CA Laws That Guide the Specifics of Clinical Practice: Treatment Records Flashcards
CA law requires that a full set of treatment records be maintained on all patients for a minimum of ___ years after treatment has been completed.
7 years.
As of January 1, 2007, the Business and Professions sCode (2919) requires that for minors, the treatment records be maintained for at least ___ years from the date the patient reaches ___ years of age (in other words, until the person is ___ years old).
- Business and Professions Code
- 7 years
- 18 years
- 25 years old
The APA provides a different set of standards pertaining to keeping records that may be followed in the absence of superseding guidelines; APA’s Record Keeping Guidelines (2007) state that psychologists may retain a full set of records for adults for ___ years after the last date of delivery of service, and for minors they may retain records for either ___ years, or ___ years after the minor reaches the age of majority, whichever is later.
- 7 years
- 7 years
- 3 years
Psychologists must keep a record of each patient visit; at minimum, each note should contain:
- Identifying data
- Date of ____________
- Type of service
- __________ with patient
- Fee
- __________ status notation
- Assessment of the patient in general terms
- Plan for ______________
- Service
- Time spent
- Mental
- Intervention
Patient records should also include:
- Consultations
- ___________/_____________ reports
- Releases of information
Summary/testing reports.
Providers using electronic record keeping must ensure the safety and integrity of the records by using:
- An ____________________ system
- An ____________________ that can copy signature documents
- A mechanism to ensure that once input, data is ________________
- Off-site backup storage
- Image mechanism
- Unalterable
Note: Original hard copies MAY BE DESTROYED once the record has been electronically stored. Additionally, policies and procedures must be implemented to safeguard confidentiality and to deny unauthorized access to records.
Adult patients, parents/guardians of minors in treatment, minor patients who have been authorized by law to consent to treatment, and patient representatives are entitled to inspect and/or obtain a copy of treatment records after presenting a __________________.
Written request.
Psychologists _____________ withhold patient records or summaries on the basis of an unpaid bill.
May not.
There are two circumstances under which a parent/guardian may be denied access to a minor’s treatment record:
- If the minor was _________________ to get treatment by him/herself, the parent/guardian may be denied access to the record
- CA law states that if the provider determines there could be a ___________________________, or that the minor’s ___________________ might be jeopardized, the parent or guardian may be denied access to the record
- Legally authorized
- Detrimental effect to the therapeutic relationship
- Physical or emotional well-being
CA law states that patients generally have a right to inspect and/or obtain a copy of treatment records; however, a treatment provider may decline to permit inspection/provide copies if the provider believes there would be _______________________________________ to the patient.
Substantial possibility of adverse or detrimental consequences.
Note: When this is the case, the provider must document the date of the request and reasons for refusing to permit inspection or provide copies of the record to the patient, including the specific adverse consequences anticipated if the patient were allowed to access treatment records.
HIPAA guidelines with regard to access to treatment records differ from CA law, and preempt CA law with regard to ___________, but not ___________.
- Adults
- Minors
HIPAA states that access to records can be denied only when the record ____________________________________.
Puts a person’s life or physical safety in danger.
The therapist must always permit the inspection of the records by or copy the records for other ________________________ designated by the patient.
Qualified professionals (psychologist, psychiatrist).
The provider must generally permit inspection of the records within ___ working days after a written request is received. When inspecting the records, the patient or patient’s representative may be accompanied by ___ other person(s) of his/her choosing.
- 5
- 1
Copies of the treatment records (at a cost not to exceed $___ per page) must generally be transmitted within ___ days after receiving a written request. Providers are not allowed to withhold records because of any unpaid bills for services.
- $0.25
- 15 days
