Chapter 17 Document It: Progress Notes

Chapter 17  Document It: Progress Notes

Complete Chapter Questions And Answers
 

Sample Questions

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?
Process notes
Progress notes
Psychotherapy notes
Payment notes

ANS: B
REF: Two Different Animals: Progress Notes Versus Psychotherapy Notes (p. 606)

What detailed information are third-party payers looking for in progress notes?
Personal content of a client’s life
Details on the therapeutic conversation
The frequency and duration of symptoms
None of the above

ANS: C
REF: Progress Notes (p. 606-607)

The goal with progress notes is to maximize client privacy while simultaneously doing which of the following?
Acknowledging the clients medical history
Documenting competent treatment that conforms to professional standards of care
Writing psychotherapy notes
Talking to third-party individuals to get a more holistic view of the client

ANS: B
REF: Progress Notes (p. 606-607)

Which of the following is an exception to the general principle of using minimal client information in progress notes?
When interviewing a child
When stabilizing a crisis situations
When meeting a family sent by the court
When a client has an affair

ANS: B
REF: Progress Notes (p. 606-607)

Which of the following is NOT one of the common ingredients of progress notes appropriate for meeting HIPAA guidelines and third-party payers?
Clients full name
Date, time, and length of session
Who attended the session
Client’s progress, including improvement or worsening of symptoms

ANS: A
REF: Progress Notes (p. 607)

Developed in response to early managed care requirements, DAP notes are one of the more common formats for progress notes. DAP stands for which of the following?
Diagnosis, assessment, plan
Diagnosis, action, progress
Data, assessment, plan
Data, action, progress

ANS: C
REF: Progress Notes (p. 607)

SOAP notes are a second widespread format for progress notes. What does the S stand for in the acronym?
Survey: using surveys to understand the client’s presenting problem
Summary: the therapist’s summary of the session
Symptoms: determining what diagnosis the symptoms meet
Subjective observations: the client’s narrative or reported symptoms

ANS: D
REF: Progress Notes (p. 607-608)