Confidentiality & Privacy
The legal mandate that governs the confidentiality of alcohol and drug abuse patient records.
What is 42 CFR Part 2 (or Federal Regulations on Confidentiality of Alcohol and Drug Abuse Patient Records)?
This section includes client statements, direct quotes, and observable behaviors during the session.
What is Data
True of False: You may write a SOAP note on another therapist's behalf if you observed the treatment.
What is False
A best practice for writing a DAP note that emphasizes specific, impactful details rather than every moment of a session.
What is being comprehensive but concise?
In a DAP note, the "Data" section combines the "Subjective" and "Objective" sections from this common note-taking format.
What is a SOAP note?
The ethical principle violated when a counselor discusses a client's history in a public setting without permission.
What is Breach of Confidentiality?
Instead of writing "the client seemed sad," you would document this objective observation.
What is "the client's mood was observed as downcast, and provided limited eye contact"?
What is Assessment
Accurate clinical documentation is crucial for proper billing and reimbursement, ensuring healthcare facilities receive appropriate compensation for services rendered.
What is Billing and Reimbursement
This note format is often seen as faster and less rigid, making it useful for high-volume practices.
What is are DAP notes?
This is what should happen if a non-custodial parent demands information about their minor child's treatment progress.
What is refuse to disclose (or require a valid court order or client consent, citing 42 CFR Part 2)?
The piece of information belongs in the Data section and involves the provider's actions during the session and the client's reaction.
What are interventions and the client's responses to them?
The 4 "P's" of the assessment section include problems, progress and _________.
What is potential?
A good rule of thumb for providers is to dedicate this amount of time to writing notes between sessions.
What is 5 to 7 minutes.
When writing a DAP note, a key challenge compared to a SOAP note is ensuring this section isn't too vague.
What is the data section?
An exception to confidentiality often triggered when a client expresses a detailed plan to harm another specific person.
What is Duty to Warn
This type of information, such as the results of a questionnaire, should be noted in the Data section.
What are screenings or assessments?
Portion of a medical report describing what treatment is recommended for the patient.
What is PLAN
To maintain professionalism and ensure readability by other healthcare professionals, you should avoid using this type of language unless it is a direct quote from the client.
What is shorthand, slang, or uncommon acronyms?
The strength of SOAP notes, which are often used in medical settings.
What is distinguished between subjective and objective findings?
The legal action a client an take against a counselor who releases their treatment information without proper consent.
What is Malpractice (or lawsuit for invasion of privacy/breach of confidentiality.
A mental health clinician would note observations about the appearance, mood, and thought process in this part of the Data section.
What is the mental status exam?
Portion of a chart note in which the results of the patient's physical examination are documented.
What is Objective
Writing notes immediately after a session helps ensure this key component of accurate documentation.
What is accuracy?
When documenting long-term behavioral changes which note type should be used?
What is DAP