Deck 6: Progress Notes

Question 1

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

A) the training they have received
B) the expectations of the client
C) legal and ethical standards
D) the requirement of the agency for which they work

Answer 1

C

Question 2

Possibly the original format for progress notes and widely used in medical contexts are _____________ notes, designed for documenting the treatment of physical symptoms.

A) DAP
B) SOAP
C) progress
D) BIRP

Answer 2

B

Question 3

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

A) client emotional and behavioral responses
B) progress and setbacks related to psychiatric symptoms
C) interventions used to treat the symptoms
D) client response to treatment

Answer 3

A

Question 4

The most ideal time to complete progress notes is __________________________.

A) twice a week
B) before the end of the day
C) at the end of the week
D) immediately following the session

Question 5

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

A) who attended and when
B) progress and symptoms
C) counselor response
D) intervention and plan

Question 6

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

A) duration; frequency; severity
B) time; date; occurrence
C) beginning; middle; current state
D) physical; mental; emotional presentation

Question 7

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

A) HIPAA notes
B) progress notes
C) psychotherapy notes
D) treatment plans

Question 8

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

A) HIPAA notes
B) progress notes
C) psychotherapy notes
D) treatment plans

Question 9

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

A) BIRP
B) SOAP
C) DAP
D) progress

Question 10

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.

Question 11

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

Question 12

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

A) Supervision that may have been sought and collateral contacts that may have been made.
B) How the client has been doing between sessions.
C) Thoughts, reflections, and opinions on the progress of the client.
D) Medical/physical concerns the counselor suspects may be present and affecting progress.

Question 13

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.

A) orientation
B) goal
C) intervention
D) diagnosis

Question 14

One of the most common formats for progress notes are _______________ notes, which were developed in response to early managed care requirements.

A) SOAP
B) BIRP
C) psychotherapy
D) DAP

Question 15

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

A) HIPAA regulations made keeping more than one set of notes illegal.
B) HIPAA regulations distinguished between progress and psychotherapy notes, opening the opportunity for counselors to keep both.
C) HIPAA distinguished psychotherapy notes as the "official" medical file.
D) HIPAA distinguished progress notes as the "official" medical file.

Question 16

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

A) a file folder with no name or label on it
B) a locked file cabinet
C) a closed office
D) a bag or briefcase

Question 17

When describing symptoms in measurable terms, the counselor should include which of the following?

A) physical, psychological, and emotional indicators
B) duration, frequency, and severity of symptoms
C) length, breath, time of behavioral episodes
D) individual, couple, and family indicators

Question 18

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

A) preparing notes with CPT billing codes
B) in noting symptom progress
C) when referring to client's family and significant others
D) when referring to diagnosis

Question 19

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

A) behavioral
B) psychiatric
C) measurable
D) emotional

Question 20

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.

A) depression
B) family issues
C) pervasive mental health issues
D) crisis situations

Question 21

How might documenting symptoms from week to week be helpful to the counseling process?

Question 22

What information should the counselor record in psychotherapy notes?

Question 23

When should progress notes be completed and why?

Question 24

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

Question 25

What parts of the session should a progress note include?