Clinical Documentation
Define the term Clinical Documentation?
What is all forms of client data.
Define the term Psychosocial Assessment.
What is a comprehensive evaluation of a client's mental health, well being, and social functioning.
What does the "S" in SOAP stand for?
What is Subjective.
_________ is a structured assessment of a client's behavior?
What is Mental status examination
True or False? Clients maintain legal ownership of their case files. Any sharing of information in a client's record must be approved by the client unless there is an urgent need to reveal information for the safety of the client or others?
What is True
Who is responsible for safeguarding privileged communication?
What is the counselor or "me"
True or False. There is no need for the Psychosocial assessment intake form to include reason for treatment?
What does the "O" in SOAP stand for?
What is Objective.
Which of the following is NOT a component of the MSE? Appearance, Speech, Pitch of Voice or Level of alertness ?
What is pitch of voice
What information should NOT be included on an intake form? Client Identification Information, Current Symptoms, Treatment History, or Credit Score?
What is Credit Score.
True or false. Guided exercise 6.1 was ethical? Brief summary: Counselor who has a busy caseload brings work home and adds case notes form the session of that day. He occasionally forgets which client said what.
What is "False" unethical.
What are the set of principles that guide the behavior of professional counselors? The ACA Code of Ethics, The ACA Code of Counseling or The ACA Code of Psychology?
What is The ACA Code of Ethics.
What does the "A" in SOAP stand for?
What is Assessment.
What question could help examine a client's mood?
What is How does the client feel? Is the client’s mood appropriate for the situation?
Types of documentation found in clinical records. Client Identification Information, Informed Consent Documents, Ancillary Information, Treatment Plans or All of the Above ?
What is All of the above.
True or false. Another reason counselors keep written records is to track their clients progress?
What is "True"
If you suspect a child has been abused or has suffered neglect. How long do you have to submit the CPS reporting?
What is no later than 48 hours.
What does the "P" in SOAP stand for?
What is Plan.
What question can help examine a client's memory?
What is Does the client have a functioning short-term memory and long-term memory?
Any type of communication between a client and a counselor is considered Privileged Communication, Private Communication or Counseling Communication?
What is Privileged Communication
Name 1 example of clinical documentation?
What is case notes, assessments results, treatment plans, documentation of telephone or electronic communication, confidentatility agreements, consent services, notices about business practice or billing notices.
Name 3 things a treatment plan would include?
What is Long Term goals, Short Term Goals, and interventions.
Why is the SOAP method important ?
What is the soap method can help new counselors with documenting the most relevant information about the session.
When year was the SOAP method developed?
What is 1964