Question 1

Generally, counselors create clinical case notes:

Accepted Answer

Counselors create clinical case notes primarily for their own use to ensure they can provide effective counseling by keeping track of client progress, treatment plans, and any changes in the client's condition.

Question 2

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

Accepted Answer

Keeping good records can benefit counselors and clients in many ways, including providing continuity of care, measuring progress in treatment, creating an accurate history of diagnosis, treatment, and recovery, and offering self-protection for counselors. However, proving that the counselor is not impaired or suffering from burnout is not a benefit of keeping good records, as this would require external evaluation or assessment rather than simply looking at records.

Question 3

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

Accepted Answer

Legal principles, such as the Health Insurance Portability and Accountability Act (HIPAA) and the American Counseling Association (ACA) Code of Ethics, recognize the confidentiality and privacy of a client's counseling records and view them as belonging to the client. The client has the right to access their own records and to control the disclosure of their information. The counselor and agency have a responsibility to protect and maintain the confidentiality of client records. Courts may request access to records, but this is typically done through a subpoena or court order and with the client's informed consent or knowledge. Insurance companies do not own the client's records and may only access them with the client's consent or as necessary for payment or healthcare operations.

Question 4

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

Accepted Answer

Upon receiving a subpoena for counseling records of a client, the best action for a counselor who works in a mental health agency is to ask their supervisor to obtain a legal opinion as to whether the records should be copied for the attorney who issued the subpoena. It is important to follow the proper legal procedures to ensure the protection of client confidentiality, and seeking legal advice is the best way to ensure these procedures are being followed appropriately. Turning over the records immediately or calling the attorney to request withdrawal could have negative consequences and may not be in the best interest of the client or the counselor. Consulting with a colleague or hiring a private attorney could also be beneficial, but obtaining a legal opinion through the supervisor is the most appropriate first step.

Question 5

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

Accepted Answer

All of the choices are important and necessary when handling audiotapes or videotapes of counseling sessions for supervision purposes. Trainees must retrieve and erase the tapes after review, supervisors must handle the tapes appropriately and return them, and the tapes should be labeled discreetly to maintain confidentiality. All these measures ensure that the tapes are kept confidential and comply with ethical guidelines.

Question 6

The three major types of records that counselors keep are:

Accepted Answer

The answer of The three major types of records that...

Question 7

Subpoenas are used:

Accepted Answer

Subpoenas can be used to obtain copies of records, to cause potential witnesses to testify at a deposition, hearing, or trial, and to require witnesses to appear at a deposition, hearing, or trial and to bring their records with them. Additionally, subpoenas can ask potential witnesses to respond in writing to written questions. Therefore, all of the above are correct choices.

Question 8

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

Accepted Answer

Clinical case notes are an essential part of a counselor's professional practice. They provide a record of the client's history, progress, and future plans. Counselors should keep only the notes that are relevant to their work and avoid including any unnecessary or irrelevant information. The notes should be kept confidential and secure to protect the client's privacy. It is important for the counselor to take necessary precautions to safeguard the notes from unauthorized access or disclosure.

Question 9

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

Accepted Answer

HIPAA allows for the disclosure of health care information to family members or others involved in the client's care if the client is informed and given the opportunity to object orally and does not do so. This provision is designed to facilitate care coordination and support among those who are helping the client.

Question 10

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

Counselor direct observations can be used against clients in criminal investigations and are not protected by the Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1972.

Question 11

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

All of the above options are circumstances under which federally funded substance abuse programs can disclose client records. Written consent, medical emergencies, audits or evaluations, and a court order to avert substantial risk of death or serious bodily harm are all valid reasons for disclosure.

Question 12

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

Accepted Answer

Counselors should avoid including their personal thoughts, diagnoses, and conclusions in documented records for self-protection as they may be subpoenaed and used against them in court. It is important to focus on factual information and avoid subjective opinions.

Question 13

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

Accepted Answer

HIPAA requires all of the above. Counselors must give clients a clear written explanation of how they use, keep, and disclose their health care information, and clients have access to their records. There must be a written process for clients to request amendments to their records, and a written history of most disclosures of client information must be available to clients.

Question 14

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

Accepted Answer

FERPA applies to all public educational institutions that receive federal funding, protecting the privacy of student education records.

Question 15

When documenting for self-protection:

Accepted Answer

When documenting for self-protection, it is important to include as much detail as possible for accuracy and credibility purposes. Dates, times, and exact words spoken can be helpful in demonstrating the counselor's actions were appropriate and ethical. It is unethical to back-date documentation or avoid including information related to disagreements with a client. The purpose of documentation is to accurately reflect the clinical process and protect both the client and the counselor.

Quiz 6: Records and Subpoenas