Well That Didn't Work
An upset person is yelling. Staff responds, "CALM DOWN!" louder than the person is yelling. Name the communication technique staff just demonstrated.
What is escalation.
These three letters mean a medication is given "as needed" rather than at a regularly scheduled time.
What is PRN.
A teenager is furious and begins yelling. you lower your voice instead of matching theirs. This technique has a name.
What is de-escalation.
Progress note: "John was being a jerk all morning." The biggest documentation problem is that "jerk" is this rather than an observable behavior.
What is an opinion/judgement?
These four letters refer to the federal law famous for protecting the privacy and security of certain health information-and for being pronounced like an animal.
What is HIPPA
A person refuses to attend an activity. Staff says, "Fine. You never participate in anything anyway." This response attacks the person rather than addressing the behavior.
What is shaming.
Staff uses this record to document medications that have been administered.
What is the MAR (Medication Administration Record)?
A young person who has been angry suddenly becomes quiet, stops responding, stares into space, and seems disconnected from what's happening around them.
What is shutting down/freezing?
Choose the better documentation:
A. "Maria was obviously attention seeking."
B. "Maria approached staff four times in 20 minutes requesting to speak privately."
What is B?
What does the Acronym CCBHC stand for?
What is Certified Community Behavioral health Clinic?
A Staff member tells a person, "You can tell me anything. I promise I won't tell anyone. " This is the promise staff should never have made.
What is a promise of confidentiality/secrecy.
A person says, "This pill looks different from the one I usually take." Instead of saying, "I'm sure it's fine," staff should do this before proceeding.
What is stop and verify the medication?
A youth tells you, "Sometimes I wish I could go to sleep and never wake up." Staff should treat this as a possible expression of this safety concern.
What is Suicidal Ideation?
Progress note: " Client became aggressive."
To make this useful documentation, staff needs to describe specifically what person did that they labeled "aggressive." In other words, document this.
Someone is having a terrible day., you don't give advice, interrupt, fix the problem, or tell them about your terrible day. Instead, you pay attention, reflect, and try to understand. This skill is called...
What is Active Listening?
A person is extremely agitated. Four staff members approach, stand around them, and begin asking questions at the same time. Name the de-escalation mistake.
What is crowding/overwhelming the person.
A person receiving medication suddenly develops difficulty breathing and swelling of the lips and tongue. This potentially life=threatening reaction requires emergency medical attention.
What is anaphylaxis/a sever allergic reaction?
During an argument, a young person is getting more agitated. You offer, "Would you rather sit here or walk with me?" Instead of making another demand, you have offered this de-escalation tool.
What is a choice?
A person says, "Nobody cares whether I Live or die." you put their exact words inside quotation marks in your documentation. This is called this type of note.
What is a direct quote?
A co-worker tells you juicy personal information about someone you serve. You have no work-related reason to know it. This principle means private information should only be shared with people who actually require it to perform their job.
What is need-to-know?
A Person is pacing and repeatedly saying, "Leave me alone." Staff follows them down the hallway saying. "We need to talk about this RIGHT NOW." What important de-escalation strategy is staff failing to provide?
What is space.
A person asks a non-clinical worker, "I've been feeling better. Do you think I can stop taking this medication?" The worker should not give medical advice and should direct the question to this professional.
What is the prescriber/appropriate medical professional?
A youth who was extremely upset suddenly becomes unusually calm after talking about suicide and begins giving away important belongings. Rather than assuming they're feeling better, staff should recoginize this as this.
What is a suicide warning sign requiring immediate safety assessment/escalation?
Progress note: "Client was manipulative and tried to staff-split."
Rewrite the central problem by replacing those labels with this kind of information: "Client asked Staff A for permission after Staff B had denied the request."
What are objective/observable facts?
A person asks for your personal phone number so they can call you whenever they need support. Saying no while helping them identify the appropriate program contact maintains these.
What are professional boundaries?