ETHICS IN BEHAVIORAL HEALTH DOCUMENTATION: REASONS, RISKS AND REWARDS Final Examination Questions Select the best answer for each question and mark your answers on the Final Examination Answer Sheet found on page 97, or complete your test online at EliteLearning.com/Book 37. Good clinical documentation primarily meets the needs of: a. The client, practitioner, & organization. b. Accrediting bodies. c. Supervisors. d. Professional boards & regulatory organizations. 38. The medical model of documentation: a. Is based on an agency’s policy. b. Is used only in hospitals. 44. 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 & limitations, & relevant history. b. Presenting problem, client’s goals, treatment progress, expected length of treatment, & insurance copay. c. Referral source, collateral information, diagnostic impression, treatment approach, & expected duration of treatment. d. Process recording from the first session, collateral contacts, consulting practitioners, & former providers.
c. Reflects counseling & social work ideology. d. Focuses on pathology rather than strengths. 39. Well-written progress notes may protect a therapist from ethical or legal sanction by: a. Proving that the therapist is qualified & competent. b. Validating that the treatment was clinically indicated & 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 & for the clinician and client to sign. 40. In determining what is reasonable & 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. 41. Personal notes or shadow records are notes that: a. Describe the personal & educated guesses made by the provider. b. A student intern creates during training while shadowing a supervising therapist. c. Include interpretation by the therapist & can be posted on social media. d. May or may not be included in the official file & may or may not be subject to subpoena, according to state law. 42. Practitioners may be reassured that their notes are appropriate by focusing on which four areas in their documentation? a. Content, process, countertrans-ference, & formulation. b. Legibility, credibility, legality, & security. c. Content, language, credibility, & access. d. Timelines, accuracy, speculation, & diagnosis. 43. 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.
45. A good progress note primarily substantiates that: a. The client & 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 & effect of treatment. d. A therapist has the training skills & is properly licensed. 46. The mother of a 14-year-old client texts the therapist & says the client is having a bad week. The mother had asked the child’s pediatrician to prescribe medication, but the doctor wants to talk to the therapist first. State laws stipulate that only children 14 years old & older have confidentiality rights. The therapist should: a. Document the mother’s text & send a text to the pediatrician. b. Refuse to discuss the client’s treatment, citing confidentiality. c. Text the mother back, stating that the therapist will not communicate via text. d. Document the text & get a signed release for the pediatrician from the mother & client. 47. A practitioner is seeing a woman for depression & anxiety symptoms. Between sessions, the practitioner receives a voice message from the woman’s husband, who reports that the client is probably not telling the worker the “whole truth” & reveals that the client has a significant alcohol use problem. What should the practitioner do about documenting this information? a. Discuss the phone call with the client at her next session & then document the discussion. b. Nothing. The practitioner should ignore it in both the client’s session & the documen-tation. c. Keep notes about the information in the voicemail in a personal or shadow file. d. Immediately call the husband back & document the phone call in the file. 48. Documenting unnecessary information may breach client privacy. Which of the following is an example of unnecessary information in the context of individual therapy? a. Specific information about a client’s family member. b. The therapist’s reactions & response to the client’s behavior. c. The client’s report of her symptoms. d. The client’s medical history.
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Book Code: PYTX1325
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