Docsity
Docsity

Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity


Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan


Guidelines and tips
Guidelines and tips

Documentation in Counseling: Roles, Procedures, and Legal Considerations in Illinois, Exams of Nursing

A comprehensive overview of documentation practices in counseling, emphasizing its importance as a clinical tool, legal document, and means to ensure continuity of care. It outlines the roles of documentation in various aspects of counseling, including clinical supervision, quality assurance, and legal proceedings. The document also delves into specific requirements for record retention in illinois, highlighting the duration for treatment and medical records. Additionally, it explores the elements of screening documentation and the comprehensive biopsychosocial assessment, which forms the foundation of client records.

Typology: Exams

2024/2025

Available from 02/21/2025

catewilliams-smith
catewilliams-smith 🇺🇸

172 documents

1 / 3

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
CADC – Documentation Questions with 100%
Correct Answers | Updated & Verified | 2024
Roles of documentation - ✔✔1. clinical tool
2. continuity of care
3. legal document
4. accountability
5. quality assurance
Documentation as a clinical tool - ✔✔chronologically details the condition of the client receiving
services, why the services were needed, services provided who delivered the services, and outcomes
achieved.
- used in supervision
- most important skill in assuring continuity of care
Documentation as means to ensure continuity of care - ✔✔ensures continuity of care, regardless of
counselor availability, changes in counselor or service provider or subsequent readmission for services.
- EASES the TRANSITION PROCESS ensuring pertinent info is available to receiving counselor/program
Documentation as a legal document - ✔✔records both counselor and client input, including what
did/did not work.
- portions of clt record may be requested by courts if clt is legally involved or in cases where the clt
brings legal proceedings against a counselor/program
pf3

Partial preview of the text

Download Documentation in Counseling: Roles, Procedures, and Legal Considerations in Illinois and more Exams Nursing in PDF only on Docsity!

CADC – Documentation Questions with 100%

Correct Answers | Updated & Verified | 2024

Roles of documentation - ✔✔1. clinical tool

  1. continuity of care
  2. legal document
  3. accountability
  4. quality assurance Documentation as a clinical tool - ✔✔chronologically details the condition of the client receiving services, why the services were needed, services provided who delivered the services, and outcomes achieved.
    • used in supervision
    • most important skill in assuring continuity of care Documentation as means to ensure continuity of care - ✔✔ensures continuity of care, regardless of counselor availability, changes in counselor or service provider or subsequent readmission for services.
    • EASES the TRANSITION PROCESS ensuring pertinent info is available to receiving counselor/program Documentation as a legal document - ✔✔records both counselor and client input, including what did/did not work.
    • portions of clt record may be requested by courts if clt is legally involved or in cases where the clt brings legal proceedings against a counselor/program

Documentation as accountability - ✔✔recording information that is used for billing purposes, financial audits or reviews to ensure compliance with various standards.

  • document time, date, duration & type of insurance Documentation for quality assurance - ✔✔the clt record provides documentation for quality assurance reviews including utilization review, peer review, and clinical supervision.
  • processes assess if the type, intensity, duration of services are appropriate for client's condition and if documents meet regulatory and agency expectations. In IL, how long are treatment records retained? - ✔✔5 years after discharge, excluding the accounting of disclosures protected by HIPPA which must be retained for 6 years. In IL, How long are medical records detained? - ✔✔7 years Screening - ✔✔Occurs at INITIAL CONTACT, purpose is to gather enough preliminary information about the clt to evaluate their need for services, eligibility for services, and appropriate level of care/service placement.
  • Focuses on CURRENT INFO regarding the PRESENTING PRBLM and the PRBLM ACUITY that resulted in the clt seeking or being referred to treatment Elements of screening documentation - ✔✔1. Referral source
  1. Presenting problems/problem acuity
  2. Background information (vocational, legal, family, living environment)
  3. Emotional/mental status (degree of danger to self/others, ability to participant in tx)
  4. Client strengths and preferences