Case Management & Documentation Flashcards
7 cards from real CLT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Case Management & Documentation flashcards as text
Which documentation practice BEST supports continuity of care when a LEAP client is discharged from inpatient to outpatient services?
Answer: Providing a comprehensive transition summary including LEAP alliance status and current goals
A comprehensive transition summary including LEAP-specific alliance information ensures the outpatient therapist can maintain therapeutic momentum without restarting rapport-building.
A LEAP therapist discovers an error in a signed progress note. The correct action is to:
Answer: Cross out the error with a single line, add the correction, date and initial it, and keep the original legible
Proper error correction preserves the integrity of the medical record while clearly documenting the amendment, which is required by legal and ethical standards.
A client's case manager calls requesting an update on LEAP session progress. Without a signed ROI, the therapist should:
Answer: Neither confirm nor deny the client's involvement without written consent
Without a valid release of information, therapists must not confirm or deny a client's treatment status to protect confidentiality under HIPAA.
In LEAP case management, 'partnering' goals documented in the treatment plan should reflect:
Answer: Collaborative objectives that align the client's own priorities with clinical recommendations
LEAP's partnering phase emphasizes building shared goals that honor what the client values, making documented goals truly collaborative.
How long must a LEAP therapist in the US typically retain adult client records after the last date of service?
Answer: 7 years (or per state law, whichever is longer)
Federal guidelines and most state laws require mental health records for adults to be retained for at least 7 years from the last service date, with some states requiring longer.
A LEAP therapist is documenting a client who has anosognosia. Which progress note language BEST reflects accurate clinical documentation?
Answer: 'Client's awareness of illness is limited; he does not believe he has a psychiatric condition, consistent with anosognosia.'
Anosognosia is a neurological symptom, not willful denial; accurate documentation uses clinical language that reflects this distinction and avoids stigmatizing terms.
When a minor client receiving LEAP therapy turns 18, the therapist must:
Answer: Obtain a new informed consent and potentially a new release of information from the now-adult client
Upon reaching the age of majority, the client gains full legal authority over their own records and treatment decisions, requiring updated consent documentation.