What's Missing From Your Charts: Writing Great Progress Notes

1. The presenter stated that most therapists feel confident about their notes, and feel they received adequate training regarding notes.(Required)

a. True

b. False

2. Good notes are essential because they are required by:(Required)

a. Law

b. Ethics codes

c. Licensing boards

d. All of the above

3. The presenter urged therapists to think of their charts in what way?(Required)

a. They are our charts, and thus we can write them in whatever way is helpful to us.

b. As long as a chart is readable to the therapist, this is all that is necessary.

c. They are not "our charts" -- we are the custodian of our clients formal medical record.

d. If you don't work with insurance or have a great memory, you don't need to have great notes.

4. Clinical documentation in client’s chart should include:(Required)

a. Initial intake

b. Treatment plan

c. Ongoing progress notes

d. All of the above

5. Which does not need to be in a progress note?(Required)

a. Interventions

b. Topics discussed

c. Amount paid by the client for the session

d. Symptoms

6. The presenter stated that:(Required)

a. Maximizing abbreviations and using checklists is a good way to save time.

b. Signing your notes is unnecessary.

c. Notes can be illegible to others as long as you can explain the content.

d. None of the above

7. When using the SOAP notes template the P stands for:(Required)

a. Prognosis

b. Plan

c. Presentation

d. Process

8. When writing notes, therapists should:(Required)

a. Avoid cutting and pasting

b. Write as if the client may read it

c. Write as if a reviewer may read it

d. All of the above

9. Altering and changing records should be done:(Required)

a. If the notes are being requested by the client

b. In the future when you get around to adding more details

c. Never -- only dated additions are allowed

d. When the notes are requested for review

10. Actual session start and stop time should be included in the notes.(Required)

a. True

b. False

11. Common requirements for intake include:(Required)

a. Current medications

b. Symptoms, problems, and problem history

c. Diagnosis and support for it

d. All of the above

12. Insurance plans will pay for treatment:(Required)

a. Whenever a client requests it, since they paid the premium

b. Only when a client is referred by their doctor

c. When treatment is felt to be needed -- usually when a client has more than just a DSM diagnosis, more than a Z code

d. Both b and c

13. If an Insurance Plan asks for a client’s charts, therapists should:(Required)

a. Release HIPPA psychotherapy notes

b. Ask the minimum they will accept

c. Rewrite the records

d. None of the above

14: Even out-of-network therapists can have charts and care reviewed by a health plan if a client submits an invoice for therapy to their plan.(Required)

a. True

b. False

15. If a health care plan conducts a treatment review:(Required)

a. It is usually by phone

b. The therapist should not respond without first seeking advice from an attorney

c. Notes are usually requested

d. All of the above