Communication

Question 1

What are the 2 components of patient record?

Answer 1

o A) confidential client file (practitioner notes)
o B) Client service record (client/patient record)

Question 2

What is the confidential client file

Answer 2

Practitioner notes
- Identifies the client and documents nature, delivery, progress, results or recommendations of psych services
- Utmost confidentiality

Question 3

What is the client service record?

Answer 3

Client/patient record
 Administrative component
 Dates/times of service, formal correspondence between third parties and account info
 Less sensitive but also needs to be kept confidential

Question 4

What is the client service record?

Answer 4

Client/patient record
- Administrative component
- Dates/times of service, formal correspondence between third parties and account info
- Less sensitive but also needs to be kept confidential

Question 5

What are the 2 purposes of all records?

Answer 5

o Provide a service
o Provide a record for legal accountability

Question 6

What are treatment reports?

Answer 6

 E.g. letter to dr, psychiatrist or educational psych
 More likely to have higher sensitive info

Question 7

What is a third party report?

Answer 7

 Insurance company, lawyer, court

Question 8

What language should be used for communicating with other professions?

Answer 8

Combination of lay and technical – be sure to write nothing that can be misinterpreted and explain terms as appropriate

Question 9

Psychs working in multidisciplinary teams should:

Answer 9

o clarify with colleagues the need to safeguard confidentiality of psych assessment data
o clarify the nature of info to be shared
o discuss how that info will be shared