CAASP Documentation Standards 3 — Questions and Answers
Question 1: Which principle of CAASP documentation requires that families actively participate in creating and reviewing their child's service plan?
- Family-driven care documentation (Correct answer)
- Provider-led clinical documentation
- Administrative compliance recording
- Diagnostic assessment protocol
Correct answer: Family-driven care documentation
Family-driven care mandates that families are active co-authors of service plans, not passive recipients of professionally determined goals.
Question 2: Under HIPAA as applied in children's mental health systems, which situation requires a separate written authorization before releasing records to a school?
- The school is part of the treatment team and has a signed release on file
- Sharing general directory information only
- Releasing detailed therapy notes and session content (Correct answer)
- Providing emergency contact information during a crisis
Correct answer: Releasing detailed therapy notes and session content
Detailed psychotherapy notes are separately protected under HIPAA and require a specific written authorization distinct from a general release of information.
Question 3: A youth's wraparound plan documents a goal of 'graduating high school.' Which format best captures this goal according to best practices?
- A SMART goal with specific milestones, timeline, and measurable indicators (Correct answer)
- A broad aspiration statement without numerical targets
- A clinical diagnosis code linked to the educational goal
- A narrative paragraph written entirely by the clinician
Correct answer: A SMART goal with specific milestones, timeline, and measurable indicators
SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) ensure the goal is trackable and meaningful within the service plan.
Question 4: In documenting a mandated report of suspected child abuse, what is the clinician's documentation obligation?
- Record the report made, date, time, agency contacted, and information provided (Correct answer)
- Wait for the investigation outcome before documenting the suspicion
- Document only if the abuse is confirmed by child protective services
- Use coded language to protect the child's confidentiality in the record
Correct answer: Record the report made, date, time, agency contacted, and information provided
Clinicians must document the details of the mandated report including date, time, agency contacted, and information shared at the time the report was made.
Question 5: How should a provider document a youth's refusal to participate in a scheduled service?
- Omit the session from the record entirely
- Document the refusal, attempts made to engage, and any reasons provided by the youth (Correct answer)
- Record the session as completed to maintain billing compliance
- Note it only in internal staff communication, not the official record
Correct answer: Document the refusal, attempts made to engage, and any reasons provided by the youth
Documenting refusals with engagement attempts and the youth's stated reasons demonstrates diligence and protects the provider legally and ethically.
Question 6: Which type of document captures the youth's and family's own words about their goals and priorities within a system-of-care framework?
- Clinical assessment summary written by the evaluator
- Person-centered plan or family story narrative (Correct answer)
- Diagnostic and Statistical Manual criteria checklist
- Agency intake demographic form
Correct answer: Person-centered plan or family story narrative
A person-centered or family story narrative incorporates the voice of the youth and family, reflecting their own language and priorities.
Question 7: When documenting medication management for a child in a CAASP-aligned program, which information is essential to include?
- Medication name, dose, prescriber, date prescribed, response, and any side effects noted (Correct answer)
- Only the medication name and dose for simplicity
- Prescriber's credentials and billing NPI number only
- The child's insurance formulary approval number
Correct answer: Medication name, dose, prescriber, date prescribed, response, and any side effects noted
Complete medication documentation requires the medication name, dosage, prescribing provider, start date, observed response, and any adverse effects for safe care coordination.
CAASP Documentation Standards 3
Which principle of CAASP documentation requires that families actively participate in creating and reviewing their child's service plan?