CLT Case Management & Documentation 3 — Questions and Answers
Question 1: Which documentation practice BEST supports continuity of care when a LEAP client is discharged from inpatient to outpatient services?
- Sending only the diagnosis codes to the outpatient provider
- Providing a comprehensive transition summary including LEAP alliance status and current goals (Correct answer)
- Waiting for the client to authorize all records before any communication
- Forwarding only the most recent progress note
Correct 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.
Question 2: A LEAP therapist discovers an error in a signed progress note. The correct action is to:
- Delete the original note and rewrite it
- Cross out the error with a single line, add the correction, date and initial it, and keep the original legible (Correct answer)
- Leave the error uncorrected to preserve the original record
- Shred the note and create a new one dated the same day
Correct 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.
Question 3: A client's case manager calls requesting an update on LEAP session progress. Without a signed ROI, the therapist should:
- Share a full summary verbally since it is a professional contact
- Confirm or deny the client is in treatment and provide a brief update
- Neither confirm nor deny the client's involvement without written consent (Correct answer)
- Send the entire chart electronically for coordination purposes
Correct 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.
Question 4: In LEAP case management, 'partnering' goals documented in the treatment plan should reflect:
- Goals exclusively chosen by the treatment team
- Collaborative objectives that align the client's own priorities with clinical recommendations (Correct answer)
- Goals mandated by the court or legal system only
- Symptom reduction targets set by the prescribing physician
Correct 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.
Question 5: How long must a LEAP therapist in the US typically retain adult client records after the last date of service?
- 1 year
- 3 years
- 7 years (or per state law, whichever is longer) (Correct answer)
- Indefinitely
Correct 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.
Question 6: A LEAP therapist is documenting a client who has anosognosia. Which progress note language BEST reflects accurate clinical documentation?
- 'Client is in denial and refuses to cooperate with treatment.'
- 'Client's awareness of illness is limited; he does not believe he has a psychiatric condition, consistent with anosognosia.' (Correct answer)
- 'Client is manipulative and seeking secondary gain.'
- 'Client is non-compliant and was confronted about his lack of insight.'
Correct 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.
Question 7: When a minor client receiving LEAP therapy turns 18, the therapist must:
- Automatically terminate treatment and close the case
- Transfer guardianship records to the parents permanently
- Obtain a new informed consent and potentially a new release of information from the now-adult client (Correct answer)
- Continue under the parents' original consent without change
Correct 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.
CLT Case Management & Documentation 3
Which documentation practice BEST supports continuity of care when a LEAP client is discharged from inpatient to outpatient services?