Documentation
This should be completed as soon as possible after meeting with a client to ensure details are accurate and timely.
What is a progress note?
This ethical principle requires protecting a client's private information except when disclosure is legally or ethically required.
What is confidentiality?
This skill involves giving your full attention, reflecting what you hear, and showing genuine interest in what a client is saying.
What is active listening?
This therapeutic approach helps clients identify and change unhelpful thoughts, beliefs, and behaviors that contribute to emotional distress.
What is Cognitive Behavioral Therapy (CBT)?
This practice involves recognizing your own emotions, thoughts, and reactions so you can better understand how they may impact your work with others.
What is self-awareness?
This treatment planning principle reminds us that goals should be Specific, Measurable, Achievable, Relevant, and Time-bound.
What are SMART goals?
Accepting expensive gifts from a client could create this type of ethical concern.
What is a boundary issue/ violation?
Instead of asking, "Did you take your medication?" this type of question encourages clients to share more about their experiences.
What is an open-ended question?
This technique encourages clients to explore their own reasons for change rather than being told why they should change.
What is Motivational Interviewing (MI)?
This stage of change occurs when a person is actively making changes and working toward maintaining new behaviors.
What is action stage?
This type of documentation focuses on observable facts rather than opinions, assumptions, or personal judgments.
What is objective documentation?
If you accidentally receive another client's confidential information, your first responsibility is to avoid sharing it and notify this person or department.
Who is your supervisor or the compliance officer?
This communication technique recognizes a client's strengths, efforts, or progress to help build confidence and motivation for change.
What is an affirmation?
This intervention involves identifying triggers, warning signs, coping strategies, and supports a client can use to prevent or respond to a return to substance use or unhealthy behaviors.
What is a relapse prevention plan?
This workplace skill involves respectfully expressing your thoughts, needs, and concerns while also considering the perspectives of others.
What is effective communication?
A note states, "The client was lazy and didn't care." This documentation error should be avoided because it is this.
What is subjective (not factual)?
A client sends you a friend request on your personal social media account. According to professional boundaries, your best response is generally to do this.
What is decline the request and maintain professional boundaries?
When a client says, "I don't think treatment is going to help," the best first response is often to do this before offering advice.
What is explore their concerns (or reflect and validate their feelings)?
In this approach, clinicians focus on creating safety, trust, and empowerment before processing traumatic experiences.
What is trauma-informed care?
This term describes the ability to recover, adapt, and continue moving forward after experiencing challenges or stress.
What is resilience?
If it wasn't documented, many auditors and accrediting organizations will generally consider it not to have happened. This phrase summarizes the importance of what?
What is accurate and complete documentation?
This ethical decision-making step should come before acting when you're unsure about the right course of action in a difficult situation.
What is consult with a supervisor and/or review agency policy and the code of ethics?
Research consistently shows this is one of the strongest predictors of positive treatment outcomes, regardless of the specific therapy used.
What is the therapeutic relationship (or therapeutic alliance)?
This skill helps clients manage intense emotions by using strategies such as grounding, mindfulness, and distress tolerance.
What is emotion regulation (or DBT skills)?
These 2 concepts reminds helping professionals that understanding a person's experiences, culture, values, and circumstances is necessary before making assumptions about their behavior.
What is cultural humility and person-centered care?