Free PSS Documentation, Person-Centered Language, and Goal Setting Questions and Answers 1 — Questions and Answers
Question 1: Which of the following progress note entries uses the most objective and person-centered language?
- Peer was manipulative and attention-seeking today.
- Peer seemed less depressed and more compliant with his plan.
- Peer arrived on time and stated he 'is feeling more hopeful' after creating a list of job contacts. (Correct answer)
- The client suffers from severe anxiety but did a good job of managing it.
Correct answer: Peer arrived on time and stated he 'is feeling more hopeful' after creating a list of job contacts.
This statement is objective because it describes specific actions and uses a direct quote from the peer ('feeling more hopeful'). It is person-centered because it focuses on the peer's own words and goals, avoiding judgment, assumptions, or clinical jargon.
Question 2: What is the primary purpose of a peer-driven goal-setting tool like a Wellness Recovery Action Plan (WRAP)?
- To allow clinicians to track a peer's compliance with treatment.
- To provide a structured way for a peer to identify their own wellness tools and create action plans. (Correct answer)
- To satisfy documentation requirements for insurance companies.
- To give the peer specialist a list of problems to solve for the peer.
Correct answer: To provide a structured way for a peer to identify their own wellness tools and create action plans.
Tools like WRAP are designed to be created and owned by the individual. They help people identify their personal wellness tools, triggers, and action plans, empowering them to take control of their own recovery journey and define what wellness means to them.
Question 3: A key difference between a provider-driven goal and a peer-driven goal is that a peer-driven goal:
- Focuses exclusively on reducing psychiatric symptoms.
- Is always approved by a psychiatrist before being implemented.
- Reflects the peer's own hopes and is expressed in their own words. (Correct answer)
- Must be accomplished within a 30-day timeframe.
Correct answer: Reflects the peer's own hopes and is expressed in their own words.
Peer-driven goals originate from the individual's own aspirations, values, and hopes for their life. They are written in the person's own words and reflect what is truly important to them, rather than focusing solely on clinical outcomes like symptom reduction.
Question 4: In SMART goal setting, what does the 'M' stand for?
- Motivational
- Meaningful
- Medical
- Measurable (Correct answer)
Correct answer: Measurable
SMART is an acronym for Specific, Measurable, Achievable, Relevant, and Time-bound. The 'Measurable' component ensures that there are concrete criteria for tracking progress toward the attainment of the goal, which helps both the peer and the specialist know when it has been accomplished.
Question 5: When documenting, a peer specialist must balance transparency with confidentiality. Which piece of information should generally NOT be included in a progress note that might be shared with a treatment team?
- The peer's stated goals for the week.
- Details of the peer specialist's personal recovery story. (Correct answer)
- A direct quote from the peer about their mood.
- Steps the peer took to work on an identified goal.
Correct answer: Details of the peer specialist's personal recovery story.
While the peer specialist's own story is a key tool in building rapport, the details of that story are personal and not relevant to the peer's official record. Documentation should focus exclusively on the peer's progress, goals, and the support provided to them.
Question 6: A peer specialist observes that a peer seems withdrawn. The peer states they are 'just tired.' How should the specialist document this interaction?
- Document only the observation: 'Peer was withdrawn and depressed.'
- Document only the peer's words: 'Peer reported being tired.'
- Document both the observation and the peer's statement. (Correct answer)
- Do not document the interaction as it was contradictory.
Correct answer: Document both the observation and the peer's statement.
Objective documentation requires recording observable behaviors ('appeared withdrawn') and the peer's own words ('stated they were 'just tired''). This approach avoids making assumptions or interpretations about the peer's feelings and respects their self-reported experience.
Question 7: Which of the following is the BEST example of a SMART goal?
- I will feel happier.
- I will exercise more.
- To improve my mood, I will walk for 15 minutes, 3 times this week. (Correct answer)
- I will get a new job someday.
Correct answer: To improve my mood, I will walk for 15 minutes, 3 times this week.
This goal is Specific (walk), Measurable (15 minutes, 3 times), Achievable (starts small), Relevant (to improving mood), and Time-bound (this week). The other options are missing one or more of these critical components, making them vague and difficult to track.
Free PSS Documentation, Person-Centered Language, and Goal Setting Questions and Answers 1
Which of the following progress note entries uses the most objective and person-centered language?