CTRS EXAM--- DOCUMENTATION
client documentation - ANSWER -IF IT IS NOT WRITTEN DOWN IT
DIDN'T HAPPEN
- includes: assessmtn summaries, treatment to program plans, progress notes,
discharge/referral summaries
-document connections between program goals, client goals and client program
involvement and client outcomes
-in all cases, documentation and written records should focus on client behavior,
rather than the specialists perceptions or guesses
-in each case, the specialist is responsible for selecting the msot significant
aspects of cleints behavior documentation
objectivity - ANSWER only info that is factual and objective
accuracy - ANSWER needed in correct spelling, grammar and punctuation
behavioral language - ANSWER focuses on clients behavior, descriptive
action words and meaningful language
consistency in information - ANSWER client to client, and between clients
and specialists
conciseness of client documentation - ANSWER sentences should be short,
succinct in nature also consistent
, consistency and accuracy of information - ANSWER has to be accurate,
objective and constant
clarity in client documentation - ANSWER the use of meaningful phrases and
ensuring clarity to the reader
meaningful phrases - ANSWER descriptive, behavioral items
technical guidelines - ANSWER legible and ink, use of abbreviations must be
approved ones
mistake entry - ANSWER just strike through the word with a singl horizontal
line, write "error: and initial date
signing notes - ANSWER all notes must be signed with professional creds
abbreviations - ANSWER only one accepted by agency
Narrative Formats: source oriented medical records (SOMR) - ANSWER -
each pro group or source normally maintains information separate from the
other professional groups or sources
change in patients condition, patients repsonse to treatment or medication, lack
of change in condition, patient or family memebersresponse to teaching
-unstructured
Problem Oriented Medical Record (POMR) - ANSWER -organized around the
clients problems rather than source of data
-comprehensive evaluation
-five parts
client documentation - ANSWER -IF IT IS NOT WRITTEN DOWN IT
DIDN'T HAPPEN
- includes: assessmtn summaries, treatment to program plans, progress notes,
discharge/referral summaries
-document connections between program goals, client goals and client program
involvement and client outcomes
-in all cases, documentation and written records should focus on client behavior,
rather than the specialists perceptions or guesses
-in each case, the specialist is responsible for selecting the msot significant
aspects of cleints behavior documentation
objectivity - ANSWER only info that is factual and objective
accuracy - ANSWER needed in correct spelling, grammar and punctuation
behavioral language - ANSWER focuses on clients behavior, descriptive
action words and meaningful language
consistency in information - ANSWER client to client, and between clients
and specialists
conciseness of client documentation - ANSWER sentences should be short,
succinct in nature also consistent
, consistency and accuracy of information - ANSWER has to be accurate,
objective and constant
clarity in client documentation - ANSWER the use of meaningful phrases and
ensuring clarity to the reader
meaningful phrases - ANSWER descriptive, behavioral items
technical guidelines - ANSWER legible and ink, use of abbreviations must be
approved ones
mistake entry - ANSWER just strike through the word with a singl horizontal
line, write "error: and initial date
signing notes - ANSWER all notes must be signed with professional creds
abbreviations - ANSWER only one accepted by agency
Narrative Formats: source oriented medical records (SOMR) - ANSWER -
each pro group or source normally maintains information separate from the
other professional groups or sources
change in patients condition, patients repsonse to treatment or medication, lack
of change in condition, patient or family memebersresponse to teaching
-unstructured
Problem Oriented Medical Record (POMR) - ANSWER -organized around the
clients problems rather than source of data
-comprehensive evaluation
-five parts
