Clinical Supervision Ethics: Therapy Records
1)

Keeping up clinical records is the responsibility of: 
 
The supervisor The supervisee The agency's office staff The supervisor and the supervisee All of the above
 
2)

Which of the following does NOT belong in the client's record? 
 
Identifying data (e.g., name, client id number) and contact information Assessment of client status Relevant cultural and sociopolitical factors All of the above None of the above
 
3)

Which of the following is/are true of informed consent:
 
a) It is a single event. b) It is a process that changes over time. c) Subsequent consent to treatment discussion should all be documented. d) b and c
 
4)

One of the informed consent forms a client must sign is consent to be treated by a trainee. This form need NOT include which of the following about the supervisee:
 
a) Professional discipline (i.e., social work, counseling, psychology, nursing) b) Specialty (i.e., counseling, clinical, school) c) Treatment philosophy or orientation d) When the supervisee received his degree
 
5)

Under HIPAA, a client does NOT have which of the following rights:
 
a) The right to request restriction on the uses and disclosures of protected health information (PHI) b) The right to request amendments of her designated record set (DRS) c) The right to request confidential communications d) The right to request an accounting of disclosures e) None of the above
 
6)

HIPAA makes some exceptions to confidentiality that include:
 
a) Threat of harm to self or others b) Any criminal activity disclosed c) Involuntary commitment d) a and c
 
7)

Potential responses to a subpoena for client information never include:
 
a) Stating that you can neither deny nor confirm that any specific individual is a client and cannot release information from any client record without a court order or client consent. b) Negotiate with the issuer of the subpoena c) Ignore the subpoena d) Modify the subpoena
 
8)

HIPAA allows free use of client information for which of the following:
 
a) Use by the therapist that originated treatment notes for further treatment. b) Use or disclosure by the therapists for training programs under supervision to practice and improve their abilities in individual, family, joint, or group counseling. c) Use or disclosure by the therapist as defense in legal or other proceedings brought by the clients. d) All of the above
 
9)

HIPAA states that a release of information form must NOT:
 
a) Advise patient of his right to receive a copy of the authorization b) Be separate from all other documents in the client's file c) State specific uses and limitations of the use of the information by the persons authorized to receive it d) State the date after which the provider can no longer disclose information e) None of the above
 
10)

The DSM has a 5-axes assessment system that includes:
 
a) Symptoms that need treatment b) Recent psychosocial stressors c) Score from the Duke Health Profile d) a and b
 
11)

A formal treatment plan includes:
 
a) Presenting Problem b) Goals of Therapy c) Time Estimate d) Interventions and methods e) All of the above
 
12)

You discover you left important information out of a progress note. You can:
 
a) Add the information to the note b) Ignore it and hope it won't be a problem c) Make a new note, date it 'today,' and state that you realize you forgot to include. . . .
 
13)

If a client won't follow your suggestions, some of the reasons may be:
 
a) They don't understand it. b) They tried it but got a negative reaction. c) They tried it but couldn't do it on one attempt. d) They don't believe it will work. e) All of the above
 
14)

Which of the following statements are true regarding whether or not a client must follow the therapist's directives:
 
a) The client never has to follow your directives. b) The client should always follow your directives. c) The client must follow your directives when their problem has legal consequences.
 
15)

Modern digital technologies have added new considerations in the field of mental health. Which of the following are true when using e-mail, mobile phone messages, and text messages?
 
a) Lack of privacy is of no concern. b) There is no potential problem of security. c) 'Caution' is the by-word when using these methods.
 
16)

Sometimes you or your supervisee must decided whether or not it is ethical to accept a gift from the supervisee/client. Factors to be considered in your decision include:
 
a) The nature of the gift b) The cost of the gift c) The therapeutic/supervisory relationship between the one giving the gift and the one receiving it d) The transference or other issues that led to giving the gift e) All of the above
 
17)

When you need to assess suicide risk in a young person, you should:
 
a) Ask the client directly b) Estimate the risk level based on a thorough assessment c) Ask parents, caregivers and other sources of collateral information for their perspectives d) Re-evaluate the risk status periodically e) All of the above
 
18)

What is the single, most helpful thing an agency can give its therapists and supervisors to help in dealing with suicidal or homicidal clients?
 
a) A good armamentarium of assessment tests b) Regular CEU classes on the topic c) Clear, written policy of management of these clients d) Support and encouragement
 
19)

HIPAA allows psychotherapy notes to be withheld from the clients under certain circumstances.
 
True False
 
20)

Health providers may refuse to give parents access to their child's health and mental health records. Which of the following is NOT an acceptable requirement?
 
a) The child is age 16 or older b) The provider believes this access would have a negative effect on his professional relationship with the child c) The provider believes this access would damage the child's physical safety d) The provider believes this access would damage the child's psychological well-being
 
21)

Disclosure of record keeping procedures is potentially a part of informed consent. What information might be needed for a client to decided whether or not to sign the consent form?
 
a) Client records may become part of an electronic file that can be accessed by a wide range of institutional staff. b) When mental health client records are released with appropriate permission to do so, from that point it's possible that they might be distributed further without the therapist's or client's knowledge or consent. c) Records released in a context of litigation may be placed in the public domain and be accessible to anyone. d) In some educational settings, federal, state, and institutional regulations require record keeping procedures that could enlarge the range of people who have access to the records of a school psychologist. e) All of the above
 
22)

The mental status exam (MSE) is to determine the client's cognitive functions, including:
 
Orientation to person, time, place, and space Concentration Judgment Short- and long-term memory All of the above
 
23)

Informed consent forms that the client signs should NOT include: 
 
Information about the supervisor that includes credentials, qualifications and approach to supervision Due process Number of supervisees for which the supervisor will be responsible Ethical codes of conduct All of the above
 
24)

According to the HIPAA definition of psychotherapy notes. Items NOT mentioned that these notes don't include are:
 
Modalities and frequencies of treatment furnished Medication preblockedion and monitoring Summaries of the diagnosis, symptoms, prognosis, and progress The complete treatment plan All of the above
 
25)

Client records that are on paper, must be protected from: 
 
Unauthorized access Water damage Fire Insect damage All of the above
 
26)

Client records that are in electronic form must be protected from: 
 
Unauthorized access Power outages or surges Insects a and b a and c
 
27)

Preservation of the context of client records includes:
 
The location in which the records are kept A given time frame during which services were delivered A specific situational context during which services were delivered a and b b and c
 
28)

Precautionary actions that can be taken to protect unintentional electronic disclosure of confidential information include: 
 
Use passwords and/or encryption to protect confidential materials Use case identification numbers, not clients' Social Security numbers to identify records Get training in special issues when using electronic media or consult with a specialist when necessary Become aware of special issues raised when using electronic methods and media All of the above
 
29)

Red flags for performance problems to pay attention to when evaluating supervisees do NOT include:
 
Chronic lateness Delinquent paperwork No alterations in interaction style or behavior Client cancellations (by client or supervisee) All of the above
 
30)

The Clinical Record is NOT:
 
A tool for education A Legal document describing the care the client received A Source of information on Licensed Clinical Social Worker A Basis for planning the client's care and treatment
 
31)

A working diagnosis, another permanent part of the record,is made based on :
 
HIPAA Regulations DSM-V LCSW None of these
 
32)

Chats,E-Mail and Skype are used as therapy techniques in:
 
Face-to-Face Therapy Electronic Therapy Both a and b None of these
 
33)

According to 'The Association of State and Provincial Psychology Boards ',the summative evaluation be given to supervisees in written form ______ during each training year
 
One time 2 times 4 times No need for summative evaluation during each training year.
 
34)

Clinical Records should be:
 
Legible Accurate Made as soon as possible after therapy completed All of these
 
35)

Lambert's Outcome Questionnaire (OQ) and its child and adolescent equivalent (Y-OQ) are used for:
 
supervisors evaluation Supervisee evaluation client evaluation Both a and b