Deck 15: Document It: Progress Notes

Question 1

How should therapists sign their progress notes?

A) Electronically
B) With initials
C) By hand and including credentials
D) All of these are correct

Answer 1

C

Question 2

Developed in response to early managed care requirements, DAP notes are one of the more common formats for progress notes. DAP stands for:

A) diagnosis, assessment, and plan.
B) diagnosis, action, and progress.
C) data, assessment, and plan.
D) data, action, and progress.

Answer 2

C

Question 3

These make up the "official" medical file, the formal medical record shared with other medical professionals, clients (upon written request), and/or in response to subpoenas. Third-party payers generally have detailed requirements for the content of these. What are they?

A) Process notes
B) Progress notes
C) Psychotherapy notes
D) Payment notes

Answer 3

B

Question 4

When is the best and most proper time to write progress notes?

A) During the session
B) Immediately after the session
C) 24 hours after the session
D) Right before the same client's next session

Question 5

Progress notes should document the specific interventions the therapist used to help the client address the problems identified in the treatment plan. Which of the following is NOT a good example of this type of documentation?

A) Used solution-focused scaling to identify steps to reduce depression over next week
B) Created genogram to increase insight related to family drinking patterns
C) Discussed work stress
D) Used solution-focused scaling to identify steps to reduce depression over next week

Question 6

Progress notes should clearly identify interventions the therapist used to help the client address the problems identified in the treatment plan. Which of the following is an example of a theory-specific intervention?

A) Identified steps to reduce depression over next week
B) Created genogram to increase insight related to family drinking patterns
C) Practiced alternatives to conflict
D) Talked about fears with client

Question 7

Progress notes should document the duration, frequency, and severity of symptoms clients report. Which of the following is NOT a good example of this type of documentation?

A) Client reports mild depressed mood most days (or five out of seven days)
B) Client reports one panic attack the past week, moderate severity
C) Client reports feeling better since starting therapy
D) Client reports decreased conflict with parents; two arguments past week

Question 8

Which of the following is NOT one of the common ingredients of progress notes appropriate for meeting HIPAA guidelines and third-party payers?

A) Client's full name
B) Date, time, and length of session
C) Who attended the session
D) Client's progress, including improvement or worsening of symptoms

Question 9

The goal with progress notes is to maximize client privacy while simultaneously:

A) acknowledging the client's medical history.
B) documenting competent treatment that conforms to professional standards of care.
C) writing psychotherapy notes.
D) talking to third-party individuals to get a more holistic view of the client.

Question 10

SOAP notes are a second widespread format for progress notes. What does the S stand for in the acronym?

A) Survey: using surveys to understand the client's presenting problem
B) Summary: the therapist's summary of the session
C) Symptoms: determining what diagnosis the symptoms meet
D) Subjective observations: the client's narrative or reported symptoms

Question 11

Jillian reported to her therapist that she had been cutting over the last week to cope with stress related to her abuser's release from prison. The therapist does a thorough assessment of the client's safety and creates a safety plan with Jillian for the next week until her next scheduled appointment. How should the therapist document the crisis issues?

A) With as little information as possible to protect Jillian's privacy
B) In writing with clear details about the assessment process and specific actions taken to ensure the safety of Jillian
C) The therapist should not document the crisis at all
D) None of these is correct

Question 12

What must the therapist do with any piece of paper that has identifying client information on it, including phone message pads or calendars?

A) Save them in the client file
B) Keep them out of sight
C) Keep them in the locked file
D) Throw them away

Question 13

What detailed information are third-party payers looking for in progress notes?

A) Personal content of a client's life
B) Details on the therapeutic conversation
C) The frequency and duration of symptoms
D) None of these is correct

Question 14

Which of the following is an exception to the general principle of using minimal client information in progress notes?

A) When interviewing a child
B) When stabilizing a crisis situation
C) When meeting a family sent by the court
D) When a client has an affair

Question 15

Approximately ____ of mental health practitioners now complete their records electronically.

A) 78%
B) 57%
C) 23%
D) 99%

Question 16

A therapist notes, "Client receptive to reframe related to work issues; less receptive to reframe of pattern related to relationship." What is the therapist documenting?

A) Symptoms and progress
B) Interventions
C) Client response
D) Plan

Question 17

"Client will bring parents to the next session." This describes:

A) client response.
B) plan.
C) crisis issues.
D) consultation.