DOCUMENTATION ESSENTIALS
What is the principle of client record management?
What is the systematic approach to organizing and maintaining client records to ensure accessibility and accuracy.
What is required before sharing a client's personal information with outside parties?
What is written consent.
(Competency 109)
What is a discharge summary?
n: What is a discharge summary?
Answer: What is the document that captures a client’s progress and outlines recommendations post-treatment.
What are professional codes of ethics?
What defines the professional context within which counselors operate to safeguard client welfare.
What is one benefit of clinical supervision or peer consultation?
What provides feedback, emotional support, and ethical guidance.(Competency 122)
What is a screening report?
What is the purpose of a report that outlines a client's needs, strengths, and challenges at the beginning of treatment.
What is a treatment plan?
What is the required documentation that outlines specific interventions, goals, and timelines agreed upon for a client’s treatment.
What is progress monitoring?
What is ongoing collection and analysis of a patient data to determine the effectiveness of the treatment, and make adjustments when necessary.
Why is adhering to Federal and State laws important?
What ensures compliance regarding the treatment of substance use disorders and protects both clients and practitioners.
Why is continuing education important for addiction counselors?
What ensures that knowledge stays current and improves client outcomes.
(Competency 121)
What is the systematic approach to organizing and managing client records?
What is client record management?
(Competency 108)
Who are third parties in the context of client confidentiality?
Who are the individuals or entities that require written consent before accessing a client’s personal information.
What document summarizes a client's progress and the recommendations following treatment?
What is a discharge summary.
(Competency 110)
What standards govern the handling of client records to ensure ethical practice?
What are agency policies and professional ethical guidelines.
(Competency 108 & 111)
What is one way a counselor can reflect on their professional performance?
What is by conducting regular self-evaluations using ethical, legal, and professional standards.
(Competency 120)
What type of report details a client's initial evaluation and needs before treatment begins?
What is a screening report.
(Competency 110)
What are the legal protections that ensure a client's privacy during record handling?
What are confidentiality laws?
(Competency 109)
How do you document treatment outcomes?
What are accepted methods and instruments used to assess the effectiveness of treatment interventions.
What principle requires counselors to respect and protect client confidentiality at all times?
What is the principle of client privacy.
(Competency 109)
What are two self-care strategies a counselor might use to avoid burnout?
What are regular exercise and therapy sessions?
(Competency 123)
What is the Health Insurance Portability and Accountability Act (HIPAA)?
What is the federal law that mandates the protection and confidentially of patient health information.
What must be recorded to show adherence to treatment goals and objectives?
What are treatment progress notes.
(Competency 111)