_____________________________ Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards
F inal E xam
ETHICS IN BEHAVIORAL HEALTH DOCUMENTATION: REASONS, RISKS, AND REWARDS
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16. Good clinical documentation primarily meets the needs of: A) The client, practitioner, and organization. B) Accrediting bodies. C) Supervisors. D) Professional boards and regulatory organizations. 17. The medical model of documentation: A) Is based on an agency’s policy. B) Is used only in hospitals. C) Reflects counseling and social work ideology. D) Focuses on pathology rather than strengths. 18. Well-written progress notes may protect a therapist from ethical or legal sanction by: A) Proving that the therapist is qualified and competent. B) Validating that the treatment was clinically indicated and appropriately provided. C) Protecting client privacy so that records cannot be used in a court of law. D) Providing spaces for the date and time of sessions and for the clinician and client to sign. 19. In determining what is reasonable and customary for the public to expect from a particular profession, the courts look to the “industry standard” for guidance. These standards can be found in: A) A profession’s code of ethics. B) A particular organization’s policies. C) States’ re-licensure requirements related to continuing education. D) The literature of a lobbying organization for that profession. 20. Personal notes or shadow records are notes that: A) Describe the personal and educated guesses made by the provider. B) A student intern creates during training while shadowing a supervising therapist. C) Include interpretation by the therapist and can be posted on social media. D) May or may not be included in the official file and may or may not be subject to subpoena, according to state law.
21. Practitioners may be reassured that their notes are appropriate by focusing on which four areas in their documentation? A) Content, process, countertransference, and formulation.
B) Legibility, credibility, legality, and security. C) Content, language, credibility, and access. D) Timelines, accuracy, speculation, and diagnosis.
22. Lack of documentation about a client’s treatment in their record continues to be debated within the profession; however, this practice: A) Protects the client by ensuring confidentiality. B) Protects the clinician from subpoena because there is nothing to present. C) Is acceptable if requested by the client in writing. D) Can increase a practitioner’s liability if they become involved in litigation. 23. The biopsychosocial assessment is the foundation of a clinical record. It describes multiple areas of the client’s life, including the: A) Presenting problem in context, client strengths and limitations, and relevant history. B) Presenting problem, client’s goals, treatment progress, expected length of treatment, and insurance copay. C) Referral source, collateral information, diagnostic impression, treatment approach, and expected duration of treatment. D) Process recording from the first session, collateral contacts, consulting practitioners, and former providers. 24. A good progress note primarily substantiates that: A) The client and therapist have a strong therapeutic alliance. B) A client will likely miss or no-show for future appointments. C) An encounter took place and details the type and effect of treatment. D) A therapist has the training skills and is properly licensed.
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