Exam 15: Document It: Progress Notes

Progress notes should clearly identify interventions the therapist used to help the client address the problems identified in the treatment plan. Which of the following is an example of a theory-specific intervention?

Progress notes should document the specific interventions the therapist used to help the client address the problems identified in the treatment plan. Which of the following is NOT a good example of this type of documentation?

Which of the following is NOT one of the common ingredients of progress notes appropriate for meeting HIPAA guidelines and third-party payers?

When is the best and most proper time to write progress notes?

A therapist notes, "Client receptive to reframe related to work issues; less receptive to reframe of pattern related to relationship." What is the therapist documenting?

These make up the "official" medical file, the formal medical record shared with other medical professionals, clients (upon written request), and/or in response to subpoenas. Third-party payers generally have detailed requirements for the content of these. What are they?

What must the therapist do with any piece of paper that has identifying client information on it, including phone message pads or calendars?

Jillian reported to her therapist that she had been cutting over the last week to cope with stress related to her abuser's release from prison. The therapist does a thorough assessment of the client's safety and creates a safety plan with Jillian for the next week until her next scheduled appointment. How should the therapist document the crisis issues?

Progress notes should document the duration, frequency, and severity of symptoms clients report. Which of the following is NOT a good example of this type of documentation?

"Client will bring parents to the next session." This describes:

Which of the following is an exception to the general principle of using minimal client information in progress notes?

The goal with progress notes is to maximize client privacy while simultaneously:

How should therapists sign their progress notes?

SOAP notes are a second widespread format for progress notes. What does the S stand for in the acronym?

Developed in response to early managed care requirements, DAP notes are one of the more common formats for progress notes. DAP stands for:

Approximately ____ of mental health practitioners now complete their records electronically.

What detailed information are third-party payers looking for in progress notes?