Clinical Supervision Ethics: Therapy Records CEUS - Chapter 4

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Chapter 4: Client’s Status Client’s Current Status There are several aspects of what a client's current status can refer to. Those useful to the client's record might be summed up as the status of clinical outcome and quality status (Linkins, Brya, and Johnson, 2011). All of them should be reviewed periodically and a copy of that review placed in the client's file. Clinical Outcome Status Clinical outcome began with a mental status examination in the first clinical session or two, which resulted in a treatment plan, both of which become part of the client's record. The client's current clinical outcome status should be reviewed in terms of the client's status within the treatment plan and the current mental status. Current Status within the Treatment Plan The treatment plan should be reviewed often, with a focus on the current status of the client in relation not only to the therapy plan, but to any other services and supports that the client is receiving (Prior Authorization Utilization Review, 2007). Report the progress that has been made towards any of the treatment plan goals. Mention whatever has motivated the progress or impeded it. Although all of these are likely in the therapy session notes, it's helpful to group them together in this review. If necessary, revise the treatment plan to fit the current status. Current Mental Status The Mental Status Examination is for the purpose of determining how the client is functioning mentally, emotionally and behaviorally at the moment of the exam. As has been mentioned, much of this is accomplished through the keen observation of the therapist. There is actually a wide variation between agencies in terms of data that is actually measured and the strategies and instruments used to collect the data. Some of the most commonly used mental status assessment measures, besides criteria in the DSM-IV, are the Duke Health Profile, the Global Assessment Scale (GAS) and the similar Global Assessment of Functioning Scale (GAF). Some agencies also use assessments of depression. Duke Health Profile (DUKE): The DUKE has been popular among health and mental health researchers since it came out in 1998. Its popularity continues to this day, probably because it's a simple to take and score self-report instrument that has a record quite good validity. There are only 17 items for the client to answer as "Yes, describes me exactly," "Somewhat describes me," or "No, doesn't describe me at all." Of the questions, seven are general attitude questions, two refer to how the client believes he can do two physical tasks, and the rest refer to how the client functioned during the past week. The assessment covers six health measures (physical health, mental health, social health, general health, and perceived health), a "stand-alone" self-esteem score, and four dysfunction measures (depression, anxiety/depression, pain, and disability). The assessment and scoring forms are freely available online (Duke University Medical Center, 2005). Global Assessment of Functioning Scale (GAF): The GAF is a revision of the Global Assessment Scale (GAS), a procedure for measuring the overall functioning capability of the client during a specified period of time. Both scales are a single-item rating scale to be filled out by the clinician. There is also a children's form of the GAF. The GAF is used by the DSM in its "multiaxial" assessment system. The system has five axes for assessment (I: Symptoms that need treatment; II: Personality and developmental disorders; III: Medical or neurological conditions that may influence a psychiatric problem; IV: Recent psychosocial stressors; V: Client's level of function). The GAF is the Axis V component (Mezzich, J. E., 2002). The GAF reflects the therapist's judgment of the client's ability to function in daily life. It looks at psychological, social, occupational functioning. The scale ranges from 1 (theoretically very ill and unable to function at all in daily life) to 100 (theoretically very healthy and totally able to function in every area of daily life). The client's 5-axes diagnosis might read as: Axis I: Adjustment Disorder with Depressed Mood, Alcohol Abuse, Cannabis Abuse Axis II: No Axis II diagnosis Axis III: Hyperthyroidism Axis IV: Divorce on (date) Axis V: GAF = 56 (on admission), GAF = 65 (on discharge) [QN.No.#10. The DSM has a 5-axes assessment system that includes:] Quality Status Quality refers more to the treatment than to the client. Every agency is pressed for quality improvement in their services by government agencies, payment sources, and clients themselves. New assessment tools frequently appear. The Center for Quality Assessment and Improvement in Mental Health (CQAIMH) has an online "finder" of mental health treatment quality assessment measures (CQAIMH, n.d.). If you find one that fits the kind of treatment you're offering a client, you can include a periodic update as to the continuing improvement of the treatment quality you're giving. Treatment Plans and Goals A mental health treatment plan is a written document that outlines the expectations for therapy. Depending on requirements of payment providers and the agency, the therapist's preferences and the severity of the presenting problem, the plan may be quite formalized or may simply be composed of loose handwritten notes. If an electronic record system is used by the agency, this may dictate the treatment plan format. Nowadays, formalized treatment plans are required more frequently than in the past. However, no matter how lose or how formalized the treatment plan is, it's always subject to change during the progression of therapy. The plan is based on needs identified during the initial assessment and diagnostic process. The process used to choose the level of care needed should be documented. Depending on the problem(s), treatment plans may include family information (Council of Juvenile Correctional Administrators, 2007). A formal treatment plan generally consists of four or five parts--objectives and goals sometimes being combined: Presenting Problem--A brief deblockedion of the most significant problem(s) to be addressed. Problems that are not urgent may be set aside for later treatment. Goals of Therapy--An annotated list of both the overall and the interim goal(s) of therapy. Long-ranged goals may not need to be measurable (Utah Division of Substance Abuse and Mental Health, 2009). Objectives--A list of measurable objectives showing what the client will do to reach a goal. Action verbs are used with identifiable outcomes such as frequency and quantity. Time Estimate--A brief estimate of the length of time and/or number of sessions needed to reach each objective Methods and Interventions--A short, annotated list of techniques that will be used by the therapist and/or the client to achieve the objectives [QN.No.#11. A formal treatment plan includes:] Often achieved via informally discussion the situation, the client should always be included in developing the treatment plan and this should be recorded in the record. Some therapists give the client a written copy of the treatment plan; others believe this can cause an unnatural feeling to the therapeutic relationship. However, a copy of the plan should always be given to a client who requests it (Fritscher, 2011). In addition to the treatment plan itself, often kept in the record is a full deblockedive summary that combines biopsychosocial information and a summary of key clinical issues; it functions as a connection between the treatment plan and the assessment. The narrative summary pinpoints diagnostic signs for any existing mental health problems, and includes both the reasons for the assessed level of care and any substitution for that level of care (Utah Division of Substance Abuse and Mental Health, 2009). Progress In many ways, psychotherapy is to a certain degree an unstructured process. This causes many clients who are experiencing guided self-discovery and behavioral change to ask themselves if therapy is helping. Repeated taking of a self-report questionnaire to track progress gives both client and therapists a chance to see what is improving from the client's perspective--the most important perspective. Self-report data given via a formal assessment has often been used to: Add to the accuracy of clinical assessments Give a basis for treatment planning Provide an objective way to track treatment progress Use clinically proven guidelines to warn therapists to get stubborn cases back on track Aid in preventing hospitalizations through warning guidance Give referral sources some outcome-based information to link patients to therapists with a proven track record of giving outstanding treatment to clients with similar needs An example of such a self-report assessment is the Patient Health Questionnaire (PHQ-9), an assessment for depression that is available online (PHQ-9, (1999). Like other most successful assessments of this sort, it's short (ten questions) with easy-to-answer questions (check the level that best suits: Not at all, Several days, More than half the days, Nearly every day). The validity of the test over time is also good. These sorts of assessments, grouped under "behavior health outcome management" (BOHM), can be used every session to track progress. With real-time scoring and report generation (which can be done in a very few moments) both clinicians and clients receive excellent evaluation about the course of treatment and whether or not adjustments to the treatment plan should be made (Lambert, 2005). Although it has not always been the case, some of the newer, more advanced assessments can reliably document improvement on a single domain more than 50% of the time and, with a multi-dimensional analysis, more than 90% of the time (Kraus, Seligman, and Jordan, 2005). With payers and purchasers alike looking for documentation of client improvement, you may want to research and evaluate applicable assessments. According to the Core Battery Conference (CBC), a core assessment battery should address three distinct areas: Quality of life, or general distress Symptom clusters (e.g., anxiety, depression, mania, psychosis, etc.) Functional domains (e.g., work and social functioning) Kraus, Seligman, and Jordan (2005) identified only one battery that met all of the criteria defined by CBC with a short questionnaire, the Treatment Outcome Package (TOP Toolkit). The free package includes assessments for children, adolescents, adults, and substance abuse, as well as a couple of assessments of client satisfaction and a wealth of other information (Behavioral Health Laboratories, 2011). As clients proceed through therapy, progress and treatment plans are reviewed and assessed, and needed changes in the treatment plan are made to reflect the progress or lack thereof. In addition to the continual assessment of progress, the process includes: Comparing progress to criteria for continued service or discharge Determination of when the client can be treated at a different level of care or treatment approach based on resolution of problems and/or priorities Treatment often ends when a frustrated client leaves prematurely. Following the procedures outlined above will hopefully reduce the number of times that happens. Problems in Not Meeting Treatment Goals Assessments aside, there will be clients who just can't seem to meet treatment goals. This seems especially true in cases involving substance abuse. The treatment plan should include reports of lack of response to treatment or meeting therapy goals, or if the client is disruptive in treatment. As you would expect, the treatment plan needs to be appropriately revised (Office of Alcoholism and Substance Abuse Services, 2010). Significant Actions Taken and Outcome The main point in again mentioning "significant actions taken and outcome" is to emphasize their importance in the psychotherapy notes. Sometimes it's helpful to gather them from the individual session notes and group them into a narrative. This can add perspective that will give good guidance as to where you should go next. Documentation for All Issues with Legal Consequences Whenever you document a therapy session or other communication with or about a client, always keep in mind the possibility that this documentation could very well sink or save you in an instance of litigation. Some tips to follow in making this documentation the most helpful it can be may sound mundane and unrelated, but with thought you'll likely see the sense of it. Competent documentation (Lifson and Simon, 1998) should be unambiguous and cognizant of grammar essentials--a misplaced modifier is not your friend: "The client is a 21-year-old admitted on 7-5-11 to ___ with a history of psychotic behavior, evaluated at the ___ Center and seen by a social worker there with a chemically induced psychosis." If you didn't make progress notes, but instead kept "process" notes to remind you of your own associations and counter-transference reactions, as well as your theories about treatment, these may not be truly be private, but may be "discoverable" in the event of litigation involving your client or between your client and you. You were reviewing your progress notes and noticed that at one point you saw a problem, evaluated benefits and risks of several treatment options, talked them over with your competent client, and outlined a treatment plan to which the client agreed. But you overlooked documenting some elements of the process. How should you handle it? Make a brand new progress note, date it "today," and write, "As I reviewed my note for (date), I see that I overlooked indicating that. . ." This will give the needed information to any who may need to read the note, it makes no attempt to hide the error, and in the event of later litigation, it will be better than no note at all. This all translates to the principle that corrections should be in real time, labeled contemporaneously, and transparent. [QN.No.#12. You discover you left important information out of a progress note. You can:] If you're bent on self-destruction as a therapist, one of the easiest ways to do this is to keep no notes or poor, incomplete notes. If you noticed something in therapy, you need to respond to it and then document that response. Although preventing liability for your sake is important, the leading rationale for good documentation is that it contributes to, facilitates and enables, and is essential to client care. Documenting or charting weekly, biweekly, or monthly does you, your clients, and even your colleagues an immeasurable disservice. These tips can be summarized in three basic rules that will minimize risk to both you and your clients (Lifson and Simon, 1998): Write smarter, not longer. If you didn't write it down, it didn't happen. Never, ever change a record. The North Dakota Department of Health (n.d.) gives several lists of what to do when "Charting with a Jury in Mind." Some of these are repetitious, which only emphasizes their importance: Basic Charting Rules: What is documented, what is not documented, and how it is documented is vital Sins of Omission: Don’t omit the obvious--e.g., failure to make an entry Shadow of a doubt: Don’t allow inaccuracies Tampering with the evidence: Don’t obliterate an entry Relying on recall – Don’t wait to chart Just the facts, Ma'am Don’t chart conclusions Record only what you see and hear Describe, don't label, events and behavior Don’t get personal Neatness counts Chronology of events: Give each entry its own page Failure to communicate – What you don’t say may hurt the patient Juries can't read minds – Document intermediate steps The appearance of error: Being at fault versus appearing to be at fault--the outcome may be the same. In notes regarding the continuity of care, be sure to note: Transfer of Health Information to hospital or specialty Transfer of Health Information to prisons or jails Discharge summary Daily do's and don'ts for charting: DO: Check the name on the patient’s chart Use ink or typewriter, not pencil Read the notes on the client before either providing care or charting Use concise phases Make entries in order of consecutive shifts and days. Write the complete date and time of each entry. Sign each entry with your title Indicate client non-compliance Be sure you know the meaning of all the terms you use Use direct patient quotes when appropriate Be accurate, factual, timely, and complete Use accepted medical abbreviations Don’t backdate, tamper with, or add to notes already written Don’t write general statements, make them specific: e.g., client is adapting to divorce; instead tell in what ways the client is adapting Don’t chart procedures in advance DON'T: Wait until end of shift to chart; either keep notes during sessions or write them immediately after the session Chart for someone else Throw away notes with errors on them, mark the error and include the sheet Erase, obliterate, or write in margins Skip lines between entries Leave a space before your signature Make derogatory remarks about the client Client Fails to Follow Clinical Directives It may be that your client--or that of your supervisee--will not progress, or will progress so slowly as to make no difference unless they follow the clinical directives, which will necessarily be part of the treatment plan. But the therapist is frustrated because a particular client continually fails to follow the clinical directives. Three questions may be asked in such situations (Relaxed Therapist, 2006): Why should your clients do anything you say? Why should your client do what you’re saying now? Why wouldn’t clients follow your suggestions? The answer to "Why should your clients do anything you say?" may be found in the relationship between you and your client and within yourself. How you see yourself and your role in the therapeutic relationship will decide to what extent you expect the client to follow your advice. If you see yourself--and perhaps more importantly, if your client sees you--as the "bus driver" to take the him to his destination, you'll be the one frustrated if the client keeps challenging the route you take because he wants you to be only the travel agent. Why should your client do what you're saying now? Because you've studied your heart out and continue to do so in order to know what direction you clients need to go in, you may have come to believe that there is only one right way to recovery. Or you may have a number of ways the client can go towards recovery, but the client believes there is likely only one way and it doesn't fit any of the ways you're suggesting. You may be the one with the therapy experience, but your client is the one with the "being me" experience. If you client says a certain way won't work for him, you'll save time, energy, and frustration if you don't try to convince him why it will work for him. Instead, find out why she thinks it won't work for her, why she or her situation are different from everyone else. There may be no different but, then again, there may be. You won't know without asking; you need to ask the client what she thinks WILL work for her. She's more likely to follow her own advice, and perhaps you can lend a helpful hand in the process--which is the way therapy works in the first place. The third question, why wouldn't your client follow your suggestion, has a number of potential answers: They don't believe it will work. They don't believe they can do it. They don't understand it. They don't want it. They fear it will make matters worse. They got a negative reaction when they first tried it. They couldn't do it at the first attempt. They couldn't do it consistently. They couldn't do it at all. [QN.No.#13. If a client won't follow your suggestions, some of the reasons may be:] Any of those feelings is likely a deal breaker. All of this is reinforcement for the need for the client to be a major part of making the treatment plan. However, there are times when the client should do what you say, and there will have to be grave consequences if they don't. Examples of these times include: If the client in therapy for alcohol treatment may have some mandatory guidelines that, if not followed, could cause harm to the client or another person. Or the therapist may be mandated to report such failures to legal authorities. The same is true for a client with a sex addiction problem, or any other problem with legal consequences. If clients of these sorts do not follow clinical directives, follow the legal protocol that you must, and document the client's failure to follow clinical directives and what you did as a result. [QN.No.#14. Which of the following statements are true regarding whether or not a client must follow the therapist's directives:] Telephone Conversations with Client and Others It may be difficult to get into the habit of writing therapy notes about telephone conversations with a client or with others, such as social workers, about them. However, it's just as important--sometimes more important--to document these calls as it is to document a therapy session. If you have a call with a social worker and that person keeps a record and you don’t, there could easily be a time when your memory does not match their notes and it could lead to problems. It's especially important to document phone calls that are related to issues with legal consequences. An example of a dilemma that could arise from not documenting a telephone call: A former client is suing you. This individual attempted to commit suicide and was hospitalized after the failed attempt. She's now claiming that you didn't sufficiently intervene when she showed symptoms of suicidal ideation. After you received the lawsuit, you looked through the clinical record and discover that you had neglected to document a call you made to a psychiatrist just before the client's suicide attempt. You consulted with the psychiatrist about the woman's suicidal ideation. It would be unethical to insert a short note about the phone call at the end of the clinical note you had written just before the woman's suicide attempt. You can only hope the psychiatrist made a note that will prove it was this woman you called about; this isn't likely, because--in the name of confidentiality--you didn't mention the client's name. E-Mails, Phone Messages, and Texts A new aspect of record keeping has arisen because of modern digital technologies. These present new clinical, ethical, and legal issues in the field of mental health. We are warned frequently of the lack of security/privacy for e-mails, text messages, and mobile phone use. How using these means of communication with or about the clients affects confidentiality is still not clear. Thus, the by-word when using these digital methods is "caution." [QN.No.#15. Modern digital technologies have added new considerations in the field of mental health. Which of the following are true when using e-mail, mobile phone messages, and text messages?] Should the actual voice-mail messages, texts, and e-mails be included in the client's clinical record? A basic and simplistic answer is that at the very least, notes on the content of these messages if they have clinical or other significance should be in the record. Messages that it may be important to archive include those during a crisis or other high-pressure situations, or if therapists are flooded with messages from clients in ways that may be or become stalking, harassment, or threatening. Phone messages from clients are not a new phenomenon. Ever since the advent of the answering machine the potential for clients leaving a message for their therapist has been a reality. There are several way to handle these messages, in addition to the aforementioned written notes about the content of the message. The message may be recorded and transferred to a CD that will be part of the client's file. If you have a digital answering system, it can give you the message as an MP3 or similar file. The file can be transferred as an e-mail attachment on some mail systems, which can then be stored on the agency's computers. If the file can't be transferred by your e-mail system, you can copy it to the same CD already mentioned. There are systems available, some free (such as Google Voice), that will save the voice-mails as recordings and e-mail them to you, along with a tranblocked (however inaccurate) of the message. You can then save it in a Web-based e-mail program or download it to the agency's computer system. The rub here is the issue of privacy. If you use a means such as this, you'll need to have your clients sign an Informed Consent form that explains risks involve in using this kind of communication because of the storage method. E-mail is becoming a common and acceptable way to for therapists and clients to communicate. It can be a time saver for needed rescheduling of appointments, eliminating the game of phone tag, busy phone lines, being put on hold, and numerous other annoying problems of phone calls. However, all is not gold when it comes to e-mail communication with clients (Zur, 2010a). What about the suicidal client that sends an e-mail you don't see for 18 hours? Or the client who, by the nature and length of their e-mail, extends the time of their session by half an hour? Or who wants a "short" answer right away to a therapy questions? Or--the list could be quite long. Also, e-mails are fundamentally vulnerable because they can be accessed by unauthorized people fairly easily, compromising the confidentiality and privacy of the communications. Encrypting your e-mails requires the complexity of public and private encryption keys and teaching clients to use them. Or you can use an Informed Consent form that delineates privacy risks so clients can choose whether or not to use e-mails. This consent form would be included with others that clients are required to sign (Zur, 2010b). The consent form may also include charges that may be incurred when the e-mails and their responses essentially extend therapy session, and any other guidelines you have for the use of e-mail with clients. All of this information must also be stated verbally in a therapy session--probably more than once. Zur (2010a) offers some excellent guidelines for using e-mail with your clients: Clarify to yourself your thoughts and feelings regarding e-mail communication with clients. What are your preferences, your limits, etc.? If you're considering using e-mails as an adjunct to therapy, make sure you become HIPAA compliant. Discuss the issue of e-mail communications with clients, when relevant, in the first session. Learn from them about their expectations and clarify your expectations and boundaries. Continue the dialogue as clinically and ethically necessary throughout the course of therapy. Make sure that your office policies include a section on the use of e-mails. If you're conducting tele-health, follow state laws, relevant codes of ethics, and have a separate informed consent, which is required in some states, such as California. Make sure your computer has a password, virus protection, firewall, and backup system. Make sure that each e-mail includes an electronic signature that covers issues such as confidentiality and security. E-mails should be printed out and included in the client's file. Texting is one of the newer methods of communication between clients and therapists. Some agencies may not allow therapists to give out their cell phone numbers, preferring that clients that call after hours be transferred to an answering service that will transfer the call to the therapist on-call. And many therapists may not want to offer 24/7/365 availability to their clients. Regardless, it's almost inevitable that there will be a time in the near future when, because of the health market becoming more and more consumer-driven, many administrative and simple communications between clients and therapists will be done via cell phones and texting. In fact, on-call therapists for an agency might have a company cell phone for use during their on-call time. This may be a problem for those older therapists who can't or won't learn to text. As with other electronic communications, issues of security, confidentiality, and privacy are an inherent part of texting. A signed Informed Consent form, like the ones mentioned above, or a list of Office Policies that the client receives on intake should be used. At the very least text messages should be summarized, and the summary placed in the client's file. However, you can also have an actual record of the text itself to place in the file (possibly with a "translation" into "real English" for the sake of others who must read the file and who are not savvy to all of the texting abbreviations). Here are several ways to keep that record (Zur, 2010b): A service such as Google Voicecan record and save phone text messages. Therapists would set it up and give that number to clients; they will then have a record of all texts. The service Missing Sync connects therapists' phones to their computers and backs up (archives) the text messages. You can use an online for-fee service, such as Treasure My Text,that stores the text messages online by allowing for simple uploads of messages via text. Some cell phones, such as iPhones, allow therapists to take screen-shots of their text messages and then send them to their e-mail address as an attachment. All of these methods involve online services and will therefore have potential--sometimes inherent--problems of security, confidentiality, and privacy. Some programs may have security measure in force, but you'll want to check them out before you use them, and always employ Informed Consent forms. HIPAA confidentiality rules are always to be considered. If you communicate with your clients through e-mail and if you store clinical records digitally, you must be sure that your computer has impeccable password, firewall, virus protection, logs, and backup systems, encryption if necessary, and other computer safety measures (Zur, 2010b). You also need to be aware that HIPAA has some special rules for "a health care provider that conducts certain transactions in electronic form (called here a 'covered health care provider')" (HIPAA, 2005): "In electronic form means: using electronic media, electronic storage media including memory devices in computers (hard drives) and any removable/transportable digital memory medium, such as magnetic tape or disk, optical disk, or digital memory card; or transmission media used to exchange information already in electronic storage media. Transmission media include, for example, the internet (wide-open), extranet (using internet technology to link a business with information accessible only to collaborating parties), leased lines, dial-up lines, private networks, and the physical movement of removable/transportable electronic storage media. Certain transmissions, including of paper, via facsimile, and of voice, via telephone, are not considered to be transmissions via electronic media, because the information being exchanged did not exist in electronic form before the transmission." If you're a covered entity, you must comply with HIPAA's Privacy Rule (HIPAA, 2003) and Security Rule (HIPAA, n.d.), which are different from the HIPAA rules that are discussed elsewhere in this course. Consultations Documentation about consultations with a social worker or another professional within your organization is just as important as documenting any other transaction or communication with or about the client. The only reason this topic has been given a section of its own is to emphasize that it's just as important as any other kind of documentation. Gifts from Clients and Reasons Accepted No blanket statement can be made that accepting a gift is either always acceptable or never acceptable. Accepting a gift from a client may be unethical at times, but there are times when it's the most ethical and/or helpful thing the therapist could do. Whether or not it's ethical may depend on several factors: The nature of the gift The cost of the gift The therapeutic relationship between the therapist and the client The transference or other issues that led to giving the gift] [QN.No.#16. Sometimes you or your supervisee must decided whether or not it is ethical to accept a gift from the supervisee/client. Factors to be considered in your decision include:] The therapist must address the issue in each individual case. The answers to a couple of questions can help find the answer: Will the acceptance or refusal of the gift adversely affect the well-being and health of the client? What is the meaning behind the gift? The setting and the nature of the therapeutic relationship influence the decision as well. It may be permissible to accept certain gifts from a client that comes in once a year for a session, but accepting the same gift from a client that is currently having weekly therapy sessions may not be permissible. The primary criterion by which to judge if the action is ethical is the client's best interest (Lyckhom, 1998). All Information Related to Suicidal, Homicidal or Abuse Concerns Even though it may be another time burden to suitably document a suicide risk assessment, it's something your supervisee sometimes must do, and you must see the he does it. It's best done immediately after a clinical evaluation of the client (Ministry of Children and Family Development, n.d.). Although it's tempting to use a form with "Yes/No" check boxes (e.g., Is the client suicidal?) or a subjective rating scale from 1-5, it's better to do a thorough risk assessment and a step-by-step narrative of the clinical judgment and planning that followed. Clear documentation that records the risk assessment, estimation of risk, approach to safety planning, treatment goals, and clinical consultation is important for a number of reasons: To make relevant information for other professionals should they need it To serve as a quality assurance checklist To indicate that good clinical care often rests on good clinical documentation To protect against malpractice If documentation is poor, the risk of litigation is high even if the clinical care was good Documentation of suicide risk in an outpatient setting should include: Initial interview Emergence or re-emergence of suicide ideation, plans, or attempts Significant changes in the client's condition Essential principles to think of when assessing risk of suicide in a young person (Ministry of Children and Family Development, n.d.) include: To find out if suicide is a concern, we need to ask clients directly. It's not possible to predict individual suicides but we can estimate risk levels based on a thorough assessment. Approaches to assessing risk need to be developmentally appropriate and matched to the age and cognitive understanding of the client. The perspectives of parents, caregivers and other sources of collateral information should be actively sought out. Risk assessment requires an active consideration of the risk/protective factors ratio. In general, the greater the number of risk factors and the fewer the protective factors, the higher the potential risk. Risk status should be re-evaluated on a periodic basis. Treatment plans should correspond to the level of assessed risk. Document all clinical decisions and treatment plans. [QN.No.#17. When you need to assess suicide risk in a young person, you should:] Perhaps the most important helpful thing an agency can give its therapists to aid in dealing with suicidal, homicidal, or other serious dangers presented by a client is a clear, written policy of management of these clients. This should include policy regarding supervision when a patient presents such dangers (Cole, 2001). [QN.No.#18. What is the single, most helpful thing an agency can give its therapists and supervisors to help in dealing with suicidal or homicidal clients?] __________________________________________________________________ Question 10. The DSM has a 5-axes assessment system that includes: a) Symptoms that need treatment b) Recent psychosocial stressors c) Score from the Duke Health Profile d) a and b e) a and c f) b and c Question 11. A formal treatment plan includes: a) Presenting Problem b) Goals of Therapy c) Time Estimate d) Interventions and methods e) All of the above f) None of the above Question 12. You discover you left important information out of a progress note. You can: a) Add the information to the note b) Ignore it and hope it won't be a problem c) Make a new note, date it "today," and state that you realize you forgot to include. . . . d) None of the above Question 13. If a client won't follow your suggestions, some of the reasons may be: a) They don't understand it. b) They tried it but got a negative reaction. c) They tried it but couldn't do it on one attempt. d) They don't believe it will work. e) All of the above f) None of the above Question 14. Which of the following statements are true regarding whether or not a client must follow the therapist's directives: a) The client never has to follow your directives. b) The client should always follow your directives. c) The client must follow your directives when their problem has legal consequences. d) a and b e) a and c f) b and c Question 15. Modern digital technologies have added new considerations in the field of mental health. Which of the following are true when using e-mail, mobile phone messages, and text messages? a) Lack of privacy is of no concern. b) There is no potential problem of security. c) "Caution" is the by-word when using these methods. d) All of the above e) None of the above Question 16. Sometimes you or your supervisee must decided whether or not it is ethical to accept a gift from the supervisee/client. Factors to be considered in your decision include: a) The nature of the gift b) The cost of the gift c) The therapeutic/supervisory relationship between the one giving the gift and the one receiving it d) The transference or other issues that led to giving the gift e) All of the above f) None of the above Question 17. When you need to assess suicide risk in a young person, you should: a) Ask the client directly b) Estimate the risk level based on a thorough assessment c) Ask parents, caregivers and other sources of collateral information for their perspectives d) Re-evaluate the risk status periodically e) All of the above f) None of the above Objective 11. Name the single, most helpful thing an agency can give its therapists to aid in dealing with suicidal or homicidal clients. Question 18. What is the single, most helpful thing an agency can give its therapists and supervisors to help in dealing with suicidal or homicidal clients? a) A good armamentarium of assessment tests b) Regular CEU classes on the topic c) Clear, written policy of management of these clients d) Support and encouragement e) All of the above f) None of the above

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