documentation
Process of collecting, confirming, and recording client information
What is documentation?
Documented process of developing a clients treatment course of treatment
What is a treatment plan
Subjective, Objective, Assessment, Plan
What are SOAP notes
Act of exchanging information through words and behaviors such as body language
What is communication
Minimum client documentation includes these 3..
What is the intake form, consent form, and treatment plan ?
What is a prescription?
Assessment, Plan, Implementation, Evaluation
What are APIE notes
Non verbal communication, such as facial expressions, gestures, mannerisms, and posture
what is body language
Health Insurance Portability and Accountability Act
What does HIPAA stand for?
Client signed and dated authorization to release their medical and personal information
What is medical release
Condition of client, Action taken, Response of client, Evaluation
What are CARE notes
Questions that offer little restriction when answering and allow reflection and clarification of thoughts and feelings
What is an open ended question
Who maintains client files if the therapist is in a private practice or an independent contractor?
The therapist
Permission given by the client after they have been informed of all the relevant facts regarding treatment
what is informed consent
what is implementation
Type of questions that are direct, usually require factual or denial statements
What is close-ended question
Using 2 locks to ensure client files are secure. Ex: having a lock on the office door and fireproof file cabinet
What is the double lock rule?
Client info that is measurable and verifiable
What is an objective
Abbreviation that stands for subjective, objective, assessment, plan, implementation, evaluation and review
What are SOAPIER notes
ability to obtain and understand information and services to make appropriate health care decisions
what health literacy