Ch 6: Documentation and record keeping in clinical settings

Question 1

Two purposes of maintaining clinical documentation

Answer 1

1. facilitates the provision of the best possible services for clients
2. documents that the level of care provided to a client meets the standards of care found in the counseling profession

Question 2

written records have the potential to

Answer 2

enhance the counseling experience
accelerate client progress
increase access to various services
protect both counselors and clients
**no universal standard exists for the style and format

Question 3

clinical documentation

Answer 3

involves any written and/or electronic record pertaining to contact between the client and counselors and work that has occurred within the counseling relationship
EX: case notes, assessment, treatment plans, confidentiality agreements, consent for services, billing notices etc.

Question 4

purpose and role of clinical documentation

Answer 4

track service delivery and progress
serve as memory aid

Question 5

case notes

Answer 5

facilitate communication among treatment professionals and promote continuity of care

Question 6

types of documentation found in clinical records

Answer 6

client ID info
informed consent docs
financial arrangements
psychosocial assessment
mental status examination results
release of info
ancillary info (test results, medical records, communication with third parties)
treatment plans
case notes

Question 7

informed consent documents

Answer 7

include a variety of information describing what the counseling process will look like, what the client can expect from the counselor, what the client will be expected to do, how services will be arranged and how they will be paid for, and what resources the client has should the serves provided be deemed inappropriate or ineffective

Question 8

consent

Answer 8

sought from individuals who are legally able to provide it

Question 9

assent

Answer 9

refers to the personal agreement to engage in therapeutic activities with the counselor
with children and minors specifically

Question 10

psychosocial assessment

Answer 10

comprehensive evaluation of a clients mental health, well being, and social functioning

Question 11

common sections of a psychosocial assessment

Answer 11

1. addresses the clients presenting problem/document the reason for seeking counseling
2. looks at the clients history with the presenting concern
3. family history
4. history of mental health

Question 12

mental status examination (MSE)

Answer 12

structured assessment of a client’s behavioral and cognitive functioning
used to develop baseline understanding of a clients presentation and aid in conceptualizing a potential diagnosis
subjective tool
usually done by psychiatrists/psychologists (counselor may participate)

Question 13

components of MSE

Answer 13

appearance
level of alertness
speech
behavior
awareness of surroundings
mood
affect
thought process
thought content
memory
ability to perform calculations
judgement
higher functioning and reasoning

Question 14

release of information

Answer 14

clients maintain legal ownership of their case files; client must consent/authorize to any release of info

Question 15

treatment plans

Answer 15

a synopsis of a counselors work with a client
include description of clients presenting problem, potential diagnosis that may apply, goals established, and strategies/interventions planned to reach goals

Question 16

three primary features of treatment plans

Answer 16

an overview: brief recap of why client is in services, symptoms experienced, how problem addressed/etc.
listing of long-term goals
listing of short-term goals

Question 17

case notes

Answer 17

the session-to-session archives counselors keep about their work with clients
document what was discussed in session , the outcome of discussions, and any plans for future sessions originating from these discussions
clear, concise, and accurate

Question 18

SOAP note

Answer 18

Subjective-objective assessment plan

Question 19

STIPS note

Answer 19

signs and symptoms
topics of discussion
interventions
progress and plan
special issue

Question 20

seven cognitive goals of STIPS

Answer 20

1. to acquire relevant facts about the client and case
2. to form diagnoses or a clinical understanding of the clients presenting problems
3. to form meaningful and effective treatment plans and goals that directly relate to a clients presenting problems
4. to understand within session process when working with clients and the relevant domains to track regarding a clients problems and within session goals
5. to understand the counseling process across sessions with clients and how to longitudinally track a clients problems and overall progress in treatment
6. to evaluate and adjust, their treatment interventions to best serve clients needs
7. to use relevant criteria to evaluate the usefulness of counseling for clients at the end of treatment and to understand how their counseling interventions have led to a particular outcome in treatment for this specific client

Question 21

DAP case notes

Answer 21

describe, assess and plan

Question 22

elements of good clinical documentation

Answer 22

purposeful
ethical
comprehensible
must be done in timely manner/up to date

Question 23

time-sensitive client info

Answer 23

CPS or APS reporting
case notes

Question 24

conditions for releasing notes

Answer 24

subpoenaed by a judge (legally required to break confidentiality)(only essential information though, not everything)

Question 25

good rule of thumb with ethical record keeping

Answer 25

if you didn’t document it, It never happened

Question 26

documents that need to be saved in client records…

Answer 26

vary state to state and dependent on your work setting

Question 27

common elements in client records

Answer 27

client interactions
client attendence
formal diagnosis and diagnostic impressions
meditation (current and historical)
types of services delivered
treatment plans
plans to prevent self-harm or harm to others
client billing information
**date, time, and purpose of interaction

Question 28

key suicide risk assessment questions

Answer 28

suicidal ideation
suicidal planning
access to means
protective factors
past experiences
future expectations

Question 29

health insurance portability and accountability act (HIPPA)

Answer 29

establishes rules for who can look at, receive, and use this personal information as well as measures health care providers must take to protect confidentiality, integrity, and security of info

Question 30

two rules included in HIPPA

Answer 30

HIPPA privacy rule
HIPPA security use

Question 31

HIPPA privacy rule

Answer 31

establishes national standards for how individually identifiable info is to be protected and kept private

Question 32

confidentiality

Answer 32

refers to ensuring client information only be disclosed to authorized individuals

Question 33

HIPPA security rule

Answer 33

sets national standards for securing personal health info (PHI) recorded electronically

Question 34

4 rules to protecting PHI

Answer 34

1. ensuring the confidentiality, integrity, and availability for all PHI personally created, received, maintained, or transmitted
2. identifying and protecting against reasonable anticipated threats to the security or integrity of PHI
3. protecting against reasonable anticipated, impermissible uses or disclosures
4. ensuring compliance by other mental health professionals with access to the clients record and PHI

Question 35

deidentification

Answer 35

a process used to prevent a clients identity from relating to information found in a case file

Question 36

safe harbor

Answer 36

method to deidentifying a case file
counselor ensures that personally identifying information is expunged from the client file

Question 37

18 pieces of info that needs to be removed

Answer 37

name
address
dates (birth, admission, etc.)
telephone numbers
vehicle identification numbers/licensce
fax numbers
device identifiers or serial numbers
email addresses
website URLS
social security
IP address
medical record numbers
biometric identifiers
health plan beneficiary numbers
photographs or videos
account numbers or client file record numbers
certificate or license numbers
code numbers

Question 38

types of electronic record keeping software

Answer 38

yellow schedule
therapy notes
care logic enterprise

Question 39

advantages of electronic record keeping

Answer 39

streamlined the way records are kept and maintained
free up more counselor time
quicker and more convenient access
conservation of space

Question 40

disadvantages of electronic record keeping

Answer 40

possible data loss
risk of a breach in confidentiality
time consuming during set-up phase
making sure the program is HIPPA compliant