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CTRS exam- documentation Questions and Answers 100% Solved
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CTRS exam- documentation
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CTRS exam- documentationclient documentation - answer-IF IT IS NOT WRITTEN DOWN IT DIDN'T HAPPEN
- includes: assessment summaries, treatment to program plans, progress notes,
discharge/referral summaries
-document connections between program goals, client goals and client program
involvement and client outcomes
-in all cases, documentation and written records should focus on client behavior, rather
than the specialists perceptions or guesses
-in each case, the specialist is responsible for selecting the msot significant aspects of
cleints behavior documentation
objectivity - answeronly info that is factual and objective
accuracy - answerneeded in correct spelling, grammar and punctuation
behavioral language - answerfocuses on clients behavior, descriptive action words and
meaningful language
consistency in information - answerclient to client, and between clients and specialists
conciseness in client documentation - answershort, succinct sentences are
recommended, also consistent
consistency and accuracy of information - answermust be accurate, objective and
consistent
clarity in client documentation - answerusing meaningful phrases and making sure it is
clear to the reader
meaningful phrases - answerdescriptive, behavioral items
technical guidelines - answerlegible and written with ink, only approved abbreviations
mistaken entry - answersimply cross out the word with a singl horizontal line, write
"error: and initial date
signing notes - answerevery note should be signed with professional creds
abbreviations - answeronly one approved by agency
Narrative Formats: source oriented medical records (SOMR) - answer-each pro group
or source typically keeps data seperate from the other professional groups or sources
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