Terms
The name of the national association that classifies patient treatment levels and criteria.
What is the American Society of Addiction Medicine (ASAM).
What is a progress note.
Read the previous progress notes on your patient before meeting with the patient and before writing your own progress noted
DO
Name at least two items a progress note should include.
Clinical services and interventions
Regular progress towards goals
Staff Signature, title, and date
Name at least 3 things that must be on a written consent form in order to release client information.
The name of the program or person releasing the information
To whom the disclosure is being made
The name of the patient
How much and what type of information to be revealed
The signature of the patient
The date of the signature
An explanation that the consent can be revoked at any time
An expiration date
Treatment goals should be SMART. Define SMART
Specific, measurable, attainable, realistic, and timely.
Documentation completed when a client leaves care at any level.
What is Discharge Summary
Erase.
DONT
Draw a line through the entry, write error and initial
What is the federal regulation concerning privacy and confidentiality of substance use treatment?
42, CFR, Part 2
Chapter 42, Code of Federal Regulations, Part 2
False. Consult your/program legal representation.
All treatment plans should list client strengths. List three possible strengths a client entering substance use treatment might have.
Honest
Intelligent
Timely
Type of note format that includes the data, assessment, and plan.
D: what client said
A: what clinician assessed (clinical judgement)
P: Plan- course of action
Document action taken following indication of a need for action
Do
Treatment plans should have what two types of goals?
Short term and long term.
It is not important to consider who will review the records when documenting recommendations for treatment.
FALSE.
Patient- give as much information as possible.
Legal system- give as little information as possible.
Dual diagnosis means
the client presents with both a substance use disorder and a mental health diagnosis.
True or False Case management is both administrative and clinical.
True.
Collaboration with resources, referrals, monitoring, evaluation.
Backdate, taper with, or add noted to previously written ones
DONT
Add a new note for any information previously not included, if clinically relevant.
Name three situations in which you would be required to break confidentiality.
child/elder abuse or neglect
suicidal client
homicidal client
What should you document on an assessment or note field where you do not have anything clinically significant to report?
N/A.
Do not leave sections blank.
What are three functions of quality assurance (QA)?
review documentation for appropriateness
establishing and measuring performance
ensuring services are in compliance with regulations
Assessing staff needs
Ensure payment
This is a type of diagnosis that should be considered when the clients signs and symptoms are similar to multiple diagnoses.
What is Differential Diagnosis.
DONT
Patient records are retained for a time period ranging from 5 to 10 years after the discharge or transfer of the patient. Know state regs.
Client can revoke an authorization to disclose at any time for any reason.
Typically true, except in some legal situations.
Free points for being brave for choosing 500 point question
:)