CA Laws That Guide the Specifics of Clinical Practice: Treatment Records Flashcards Preview

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Flashcards in CA Laws That Guide the Specifics of Clinical Practice: Treatment Records Deck (19):

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


CA notes that the provider may offer to prepare a treatment summary for a patient; if the patient agrees, the summary should be completed within ___ working days.  If extenuating circumstances exist (e.g., long treatment record), the provider must notify the patient of this and may take up to ___ days to deliver the summary.

  • 10
  • 30


A patient treatment summary should contain:

  • Chief complaints and pertinent history
  • Findings from ________________ with and ________________ to other health care providers
  • Diagnosis
  • __________ Plan and Rx prescribed
  • Progress of treatment 
  • ______________ and significant continuing problems
  • Reports of diagnostic procedures/tests
  • ______________ summaries
  • Objective findings from recent physical exams

  • Consultation
  • Referral
  • Treatment
  • Prognosis
  • Discharge


When a patient provides written authorization to release records to the BOP or a court order mandates release of records to the board, records must be provided within ___ days.  The civil penalty, payable to the board, is $__________ per day for each additional day the documents haven't been provided, after the ___th day.

  • 15
  • $1000
  • 15th


Failure to comply with a court order mandating the release of records to the BOP constitutes unproffesional conduct and may result in __________________ or __________________________.

  • Suspension
  • Revocation of one's license