Documentation Flashcards
Focus charting is used when the treatment team wants to
a. show similarities and differences between clients
b. use critical care map of client progress
C. follow diagnostic protocol
D. target both client’s problems and assets
D. target both client’s problems and assets
One of the best ways to update a treatment plan is to
A. re-interview the client and his/her family
B. complete a thorough records review
C. re-administer the assessment and compare results
D. attend a treatment team meeting with multidisciplinary professionals
C. re-administer the assessment and compare results
Developing an individualized intervention plan is easiest when
A. a comprehensive program plan is in place
B. an activity inventory is used for the client assessment
C. an activity and task analysis has been completed
D. the therapist has at least two years of experience with the client group
A. a comprehensive program plan is in place
If the CTRS wants the results of the assessment and the outcomes of the program to be most helpful to the client after discharge, the CTRS will make sure the assessment tasks and questions are
A. interdisciplinary
B. evidence-based
C. authentic
D. conceptual
C. authentic
All of the following may be questions that the CTRS uses to improve clarity and completeness to a narrative note EXCEPT
A. How did I first become are of the problems?
B. What has the client said about the problem that is not significant?
C. Is this the same problem that was exhibited last week?
D. What is the plan for dealing with the problem?
B. What has the client said about eh problem that is not significant?
Which of the following is typically not part of a progress note?
A. Setbacks for meeting goals
B. New patterns of behavior
C. Program Outcomes
D. Natural supports used for participation
C. Program Outcomes
A client in a substance abuse program states, “I am looking forward to going home, but I worry if I can maintain my sobriety.” He is expressing emotions at what level of the Krathwohl’s Affective Taxonomy
A. Responding
B. Valuing
C. Organization
D.Characterization
D. characterization
Which of the following is typically included in a discharge plan?
A. Assessment results
B. Original tx plan
C. Noted strengths and remaining concerns
D. Attendance records
C. noted strengths and remaining concerns
In which of the domains, does the statement fall under? To improve ability to locate leisure partners
Cognitive
Problem-oriented medical records have which of the following advantages over source-oriented medical records?
A. An unrestricted style and format
B. Improved ability to track problem areas and successes
C. Record of behavior change over time
D. Decreases need for staff communication
B. improved ability to track problem areas and successes
In a leisure decision-making session, the CTRS asked the client, “What skills and abilities contribute to your ability to have fun?” The CTRS’s question is at what level of Krathwohl’s Cognitive Processs Taxonomy?
A. Remembering
B. Applying
C. Analyzing
D. Evaluating
D. Evaluating
Which is the most traditional and prominent format for electronic health records?
A. Formative evaluation
B. Summative evaluation
C. Source-oriented records
D. Problem-oriented records
C. Source-oriented records
Which of the following is not an advantage of electronic health records (EHR)?
A. Private data can be easily stolen
B They provide easy access for clients and their caregivers
C. They help control health care costs
D. They promote continuity of care when clients are seen by different health care professionals
A. Private data can be easily stolen
A client with cognitive impairments is learning the sequence of bowling. After the CTRS breaks the tasks into teachable components, which reinforcement technique should the CTRS use to teach this skill?
A. Fading
B. Shaping
C. Chaining
D. Extinction
C. Chaining
