Exam 6: Progress Notes

_______________________ are considered the "official" medical file and are shared with legal and medical professionals or clients upon written request or subpoenas.

Any piece of paper that has identifying client information such as phone messages, note pads, or calendars must also be locked up when not in use.

The exception to including only minimal information in progress notes is __________________, in which the counselor must include detailed information about assessment, plans, and actions taken.

In addition to interventions, client response, next session plan, and noting crisis issues, the counselor should note which of the following?

Briefly discuss the history of standardization of progress notes, including psychotherapy notes, and the advantages of standardization.

The ethical mandates of HIPAA progress notes are to maximize client privacy while simultaneously documenting competent treatment that conforms to professional standards of care.

Progress notes are the counselors' primary means of showing that they are rendering professional care that conforms to ____________________________.

_________________________ are considered the counselors' property and must be stored separately so as not to be considered part of the medical file.

Progress notes document all of the following parts of the session EXCEPT: ______________________________.

The defining element of a progress note is to document changes in the __________, _____________, and _____________ of symptoms.

When should progress notes be completed and why?

In progress notes it is preferable to use abbreviations such as AF, AM, CF and CM when __________________________________.

The appropriate place for progress notes when they are not being worked on is which of the following?

The newest and most increasingly popular format for progress notes, and the type closest to the format presented by the author is the ___________________ note.

Which of the following statements is most true regarding HIPAA regulations and documentation?

The most ideal time to complete progress notes is __________________________.

Symptom progress should be notes in all of the following terms EXCEPT: ________________.

What parts of the session should a progress note include?

Once the symptom has been identified, the progress note needs to clearly identify which theory specific _______________ the counselor used to help address the client problem.

To increase uniformity, HIPAA guidelines and third-party payers provide guidance on the ingredients of progress notes, which include all of the following EXCEPT: __________________________.