Name That Diagnosis
Excessive worry more days than not for 6 months, plus restlessness and sleep disturbance. What diagnosis does this sound like?
What is Generalized Anxiety Disorder?
The “S” in SOAP notes stands for this.
What is Subjective?
You see your client at the grocery store. Ethically, you should do this.
What is allow the client to initiate contact and if they do then engage?
Client expresses vague sadness but denies suicidal intent or plan.
What is Not Baker Act?
“Grounding skills” generally refer to techniques that do this.
What is bring someone back to the present moment?
Mood swings ranging from energetic/euphoric to hopeless/depressed, lasting days to weeks. What diagnosis does this sound like?
What is Bipolar I Disorder?
Documenting “Client reports increased irritability and poor sleep this week” belongs in which section of SOAP?
What is Subjective?
A teen client discloses they drank alcohol once at a party. You should consider this ethical principle before acting.
What is confidentiality and its limits?
Client says, “Sometimes I wish I wouldn’t wake up,” but denies plan or intent and has protective factors.
What is Not Baker Act?
The term for emotions rising rapidly and feeling uncontrollable.
What is emotional dysregulation?
Intrusive memories, avoidance, hyperarousal, and negative mood changes for over a month after trauma. What diagnosis does this sound like?
What is PTSD?
The portion of a note that includes clinical impressions and diagnoses.
What is Assessment?
A clinician is attracted to a client. The required ethical step is…
What is seek supervision/consultation?
Client reports hearing voices telling them to hurt themselves but says they have no intention to act.
What is Possibly Baker Act — depending on functional impairment and inability to ensure safety?
A DBT skill using pros/cons, acceptance, and mindfulness is called this.
What is Wise Mind?
A child shows limited eye contact, restricted interests, and difficulty with social communication. What diagnosis does this sound like?
What is Autism Spectrum Disorder?
Writing “Client visibly trembled and avoided eye contact” is documenting what type of information?
What is Objective?
A parent requests notes for their minor child, but releasing them could cause harm. You should apply this guideline.
What is the “best interest of the client” ethical standard?
Client states, “I’m going to kill myself tonight. I have a gun in my room and I’m done.”
What is Baker Act?
The cognitive distortion where someone sees things as all good or all bad.
What is black-and-white (or all-or-nothing) thinking?
Recurrent unexpected panic attacks followed by worry about additional attacks and behavior changes. What diagnosis does this sound like?
What is Panic Disorder?
Medical necessity in documentation requires showing three things: symptoms, functional impact, and this.
What is a clinically appropriate intervention/treatment plan?
You receive a subpoena for client records. The ethically appropriate action is…
What is consult legal counsel and only release minimum necessary information?
Client with paranoid delusions stops eating and drinking because they believe the food is poisoned, cannot care for themselves, and refuses treatment.
What is Baker Act (due to self-neglect and inability to protect themselves)?
The therapeutic concept where a client reenacts unresolved dynamics from early relationships with the therapist.
What is transference?