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665 WEEK 2 QUESTIONS AND VERIFIED
RATIONALIZED ANSWERS 100%
GUARANTEED A+
Documentation - Correct answer.Records benefit clients by documenting their history, their current
condition and the services they've received..."
"...help practitioners plan treatment, monitor whether that treatment is working and protect themselves
from liability in cases of legal or ethical proceedings..."
"Plus, the federal government, states and third-party payers have their own rules about record-keeping."
HIPAA - Correct answer.Health Information Portability and Accountability Act of 1996 (HIPAA)
Clients have right to access, see, and copy medical records
Right to request amendments be made to record
Right to request restriction be placed on disclosure of protected health information
PrgoCovered entities are required to provide clients with clear, written explanation of how protected
health information can be used and disclosed
Progress Notes - Correct answer.Each client "contact" should include a note
Includes calls and "drop-ins"
Progress Note: covers the who, what and when of each session.
, Progress note MAY want to include...(CAMFT, 2007)
-Treatment modality used
Progress, and/or lack of progress
-Treatment plan
-Modification(s) of the treatment plan
-Clinical impressions regarding diagnosis, and or symptoms
-Relevant psychosocial information
-Safety issues; danger to self/others
-Clinical emergencies/actions taken
-Medications used by the patient
-Treatment compliance/lack of compliance
-Clinical consultations
-Collaboration with other professionals
-Therapist's recommendations
-Referrals made/reasons for making referrals
-Termination/issues that are relevant to the termination process
-Issues related to consent and/or informed consent for treatment
-Information concerning child abuse, and/or elder or dependent adult abuse
-Information reflecting the therapist's exercise of clinical judgment
Why do we need progress notes - Correct answer.Why do we need progress notes?
"Without progress notes, it would be difficult, if not impossible, for a therapist to create a health care
record that accurately reflects his or her sound clinical judgment, the standards of the profession, and
the nature of the services being rendered.
Furthermore, progress notes provide a therapist with an opportunity to document his or her exercise of
judgment in dealing with complex and challenging treatment scenarios."
...Documentation protects the client AND the therapist.
665 WEEK 2 QUESTIONS AND VERIFIED
RATIONALIZED ANSWERS 100%
GUARANTEED A+
Documentation - Correct answer.Records benefit clients by documenting their history, their current
condition and the services they've received..."
"...help practitioners plan treatment, monitor whether that treatment is working and protect themselves
from liability in cases of legal or ethical proceedings..."
"Plus, the federal government, states and third-party payers have their own rules about record-keeping."
HIPAA - Correct answer.Health Information Portability and Accountability Act of 1996 (HIPAA)
Clients have right to access, see, and copy medical records
Right to request amendments be made to record
Right to request restriction be placed on disclosure of protected health information
PrgoCovered entities are required to provide clients with clear, written explanation of how protected
health information can be used and disclosed
Progress Notes - Correct answer.Each client "contact" should include a note
Includes calls and "drop-ins"
Progress Note: covers the who, what and when of each session.
, Progress note MAY want to include...(CAMFT, 2007)
-Treatment modality used
Progress, and/or lack of progress
-Treatment plan
-Modification(s) of the treatment plan
-Clinical impressions regarding diagnosis, and or symptoms
-Relevant psychosocial information
-Safety issues; danger to self/others
-Clinical emergencies/actions taken
-Medications used by the patient
-Treatment compliance/lack of compliance
-Clinical consultations
-Collaboration with other professionals
-Therapist's recommendations
-Referrals made/reasons for making referrals
-Termination/issues that are relevant to the termination process
-Issues related to consent and/or informed consent for treatment
-Information concerning child abuse, and/or elder or dependent adult abuse
-Information reflecting the therapist's exercise of clinical judgment
Why do we need progress notes - Correct answer.Why do we need progress notes?
"Without progress notes, it would be difficult, if not impossible, for a therapist to create a health care
record that accurately reflects his or her sound clinical judgment, the standards of the profession, and
the nature of the services being rendered.
Furthermore, progress notes provide a therapist with an opportunity to document his or her exercise of
judgment in dealing with complex and challenging treatment scenarios."
...Documentation protects the client AND the therapist.
