Client report writing

P 485 Topic 1

Dq1

What are the major requirements that must be made for documentation of a new client and an ongoing client? What are the possible consequences if a counselor does not follow required record-keeping practices?

 

DQ 2

What are the legal standards for clinical documentation in the state in which you plan to practice? How are they different than federal regulations? How are they similar?

 

Assignment 1

 

Complete the Standard Abbreviations Worksheet.

APA style is not required, but solid academic writing is expected.

 

 

PCN-485 Standard Abbreviations for Counselors/Behavioral Health

ACA

 

Adult Children of Alcoholics

 

ADD

 

Attention Deficit Disorder

 

ADHD

 

Attention Deficit Hyperactivity Disorder

 

AMA

 

Against Medical Advice

 

Appt.

 

Appointment

 

B.P.

 

Blood Pressure

 

(B)

 

Brother

 

C

 

With

 

CD

 

Chemical Dependency

 

C.N.S.

 

Central Nervous System

 

Ct.

 

Client

 

C/o

 

Complains of

 

DUI

 

Driving under the influence

 

DSM-5

 

Diagnostic and Statistical Manual of Mental Disorders-5th ed.

 

DWI

 

Driving while intoxicated

 

Dx

 

Diagnosis

 

ECT

 

Electroconvulsive therapy

 

E.D.

 

Emergency department

 

E.R.

 

Emergency room

 

ETOH

 

Ethel alcohol

 

Eval

 

Evaluation

 

=

 

equal

 

<

 

Less than

 

>

 

Greater than

 

(F)

 

Father

 

Hx

 

History

 

I.Q.

 

Intelligence quotient

 

I.V.

 

Intravenously

 

Lbs.

 

Pounds

 

L.S.D

 

Lysergic Acid Diethylamide

 

Meds.

 

Medication

 

(M)

 

Mother

 

MSE

 

Mental Status Exam

 

Neg.

 

negative

 

–

 

negative

 

n/a

 

not applicable

 

#

 

number

 

n/s

 

no show

 

PCP

 

Phencyclidine

 

Pt.

 

Patient

 

P.O.

 

Probation officer

 

+

 

Plus

 

R/O

 

rule out

 

(S)

 

Sister

 

TD

 

Tardive Dyskinesia

 

THC

 

Tetrahydrocannibinol

 

Tx

 

Treatment

 

 

 

 

 

 

 

 

Standard

 

 

Abbreviations Worksheet

 

Directions: Edit the following clinical note using standard abbreviations where applicable. Use the “Standard Abbreviations for Counselors” resource to guide you through completion of the worksheet.

 

Clinical Note:

 

Today, Joe came into the office for his regularly scheduled counseling appointment. Today’s visit was to review his assessment by the resident psychiatrist to explore what his diagnosis was. The psychiatrist used the Diagnostic and Statistical Manual of Mental Disorders-5th Edition to review the symptoms Joe was experiencing. Since Joe was arrested three weeks ago for driving under the influence, it was determined that he could be suffering from substance use issues. Client reports he is not currently on any medication, but is complaining of symptoms of depression and anxiety, as well as craving a drink.

 

After obtaining a release of information from his probation officer, it was learned that Joe is facing charges of driving under the influence, and has a prior history of this behavior. He has been arrested twice before. In his most recent stay in jail, he was talking about how depressed he was, and the jail called the counselor. That counselor referred Joe to the psychiatrist. Joe disclosed that on a recent trip to the emergency room, after he had a panic attack, he decided that it was time for a change. At first, he thought his blood pressure was too high and he was having a heart attack. Against medical advice, Joe left the emergency room without receiving any medication for his anxiety. He left with his brother and decided to call the psychiatrist.

 

After reviewing the diagnosis made by the psychiatrist, and explaining the purposes of the Diagnostic and Statistical Manual of Mental Disorders-5th Revision, Joe decided to schedule another appointment to obtain a mental status exam, as well as schedule a treatment planning session.

 

Sarah Smith, , LPC October 29, 2013

Case Manager Signature Date

 

 

 

 

 

 

 

 

 

 

 

Assignment 2

 

Complete the “Client Intake and HIPAA Worksheet.”

Client Intake and HIPAA Worksheet

 

Part 1:

 

1. Imagine that you are a case manager working with a new client. In an answer of 250-500 words, describe the forms that you would use to intake the client. Include the purpose of each form in your answer. Also, include at least one scholarly reference to support your response.

 

 

 

 

2. Conduct an Internet search for three different intake forms. Compare and contrast the forms found during your search. How are they similar? How are they different? What is the benefit of having a detailed intake form?

 

 

 

Part 2:

 

Scenario: James’s wife is waiting for him in the lobby of the agency while he is in session with his case manager. In the waiting room, there are several other clients and professionals waiting to be seen by their case manager or waiting for a meeting to begin. When the case manager comes out of her office with James, his wife approaches her, requesting information about James, his medication, and his diagnosis. The other people in the waiting room are staring at her, then at James, then at the case manager expecting something to happen. James’s wife wants to know if he can stop taking the Xanax, because it makes him act “funny.” Plus, she said that he was denied his medical card because she makes too much money and wants to know if the case manager can provide the service for no cost.

 

Imagine that you are James’s case manager. In an answer of 250-500 words, describe how you would handle this situation to ensure that you are complying with confidentiality and HIPAA regulations. Include at least one scholarly reference to support your respon