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 of the following is an example of appropriate use of SOAP note format for a LEAP session?
Answer: S: Client stated 'I don't have any illness.' O: Client maintained eye contact, spoke clearly. A: Client shows limited illness insight; LEAP empathy-listening phase continuing. P: Explore client's personal goals next session.
A well-formed SOAP note places the client's own words in Subjective, observable data in Objective, clinical interpretation in Assessment, and next-session direction in Plan.
A LEAP therapist receives a subpoena for a client's records. The FIRST step should be to:
Answer: Consult with an attorney and notify the client before releasing any records
A subpoena is not automatically a court order; consulting legal counsel and notifying the client allows the client to assert privilege if applicable.
In LEAP documentation, tracking the 'Agree' phase would MOST likely involve noting:
Answer: Areas where the client and therapist found genuine common ground, such as shared concerns about quality of life
The Agree phase in LEAP is about identifying authentic points of agreement, particularly around the client's own quality-of-life concerns, which should be explicitly documented.
Which of the following best describes the purpose of a 'no-harm safety plan' in a LEAP client's case file?
Answer: To provide a collaborative, individualized document the client helps create to manage crises safely
An effective safety plan is a collaborative tool co-created with the client, listing personalized warning signs, coping strategies, and contacts — not a legal waiver.
A LEAP therapist is preparing a case summary for utilization review. Which information is MOST essential to include?
Answer: Clinical evidence of medical necessity, treatment progress, and goals for continued care
Utilization reviewers determine whether continued services are medically necessary; documentation must demonstrate clinical need, progress, and ongoing treatment goals.
Documentation of 'informed consent' for LEAP therapy should include evidence that the client was told about:
Answer: The nature of LEAP, expected benefits and risks, confidentiality limits, and the right to withdraw
Informed consent must cover what the treatment involves, its benefits and risks, confidentiality limits, and the client's right to discontinue treatment.
When using an electronic health record (EHR) system for LEAP documentation, which security practice is MOST important?
Answer: Using a unique, strong password and logging out after each session
Using unique credentials and logging out after each session protects against unauthorized access and maintains the integrity of confidential records under HIPAA.