Preventive & Diagnostic Healthcare
This type of healthcare focuses on preventing mental health issues before they develop or worsen.
What is preventive healthcare?
These are written records that document a client's progress, therapeutic interventions, and treatment plans during sessions.
What are progress notes?
Before sharing a client's personal information with outside parties, a mental health professional must obtain this from the client.
What is a release of information consent?
This document ensures that clients are fully aware of their rights and the details of the treatment they will receive before beginning therapy.
What is informed consent?
This term refers to the detailed written records kept by mental health professionals to track a client’s therapy and progress.
What is clinical documentation?
The assessment method used to determine if a client has a mental health condition, often involving interviews and tests, is known as this.
What is diagnostic evaluation?
In progress notes, this type of documentation helps in tracking changes and outcomes over time, and is crucial for treatment planning.
What is ongoing assessment?
This document specifies the details of what client information can be shared, with whom, and for how long.
What is a release of information form?
Clients have the right to refuse treatment or withdraw consent at any time, which is an essential aspect of this concept.
What are client rights?
Clinical documentation must adhere to these standards to ensure accuracy, privacy, and compliance with legal and ethical guidelines.
What are documentation standards?
This type of preventive care involves regular check-ups and screenings to detect potential health issues before symptoms arise.
What is routine screening?
Progress notes should be documented in this manner to ensure they are clear, objective, and professional.
What is a SOAP format?
This type of release is necessary for sharing a client’s records with other healthcare providers for continued care or coordination of services.
What is a coordinated care release?
This document is used to inform clients about their rights to privacy and the limits of confidentiality in therapy.
What is a privacy notice?
Clinical documentation must be completed within this time frame to ensure accuracy and continuity of care.
What is within 24 hours of the session?
An assessment performed before starting treatment to establish a baseline for mental health and well-being is known as this.
What is a baseline assessment?
These notes are important for tracking a client's therapeutic progress and ensuring continuity of care, particularly when different therapists are involved.
What are treatment records?
This legal document must be signed by the client before any sensitive information can be disclosed to third parties.
What is an authorization form?
This process ensures clients understand the nature of their treatment and consent to it, including potential risks and benefits.
What is informed consent?
Maintaining this in clinical documentation helps ensure that records are complete and up-to-date.
What is thoroughness?
This approach to preventive healthcare aims to identify risk factors and intervene early to prevent the onset of mental health disorders.
What is early intervention?
When documenting progress notes, this principle ensures that all information is relevant and non-biased.
What is objectivity?
The process of obtaining and documenting a client’s consent to release information must adhere to this principle to protect client confidentiality.
What is confidentiality?
Clients must be given this before beginning treatment, to ensure they are fully aware of their rights and the treatment process.
What is a rights and responsibilities statement?
Clinical documentation should include these elements to provide a comprehensive record of the client’s progress and treatment.
What are treatment goals, interventions, and outcomes?