Case Management and Documentation Flashcards

Which acronym describes the format commonly used for writing behavioral health progress notes?

Answer: Both DAP and SOAP are commonly used

Both DAP and SOAP are widely accepted progress note formats used in behavioral health and addiction counseling settings.

A MAC counselor suspects a client is homeless but the client has not disclosed this. The most appropriate case management action is to:

Answer: Directly and sensitively ask the client about their housing situation

Directly and sensitively inquiring about housing allows the counselor to accurately assess the client's needs and offer appropriate resources.

Client records must be retained for a minimum period after the last service date primarily to:

Answer: Comply with state licensing laws and support continuity of care

State licensing regulations specify minimum record retention periods to ensure legal accountability and support continuity of care for returning clients.

When a client gives consent for a referral to a mental health provider, the referral letter should include:

Answer: Reason for referral, relevant clinical history, and contact information

An effective referral letter provides the receiving provider with clinical context, the reason for referral, and contact details to facilitate seamless care coordination.

Which of the following is an example of a warm handoff in addiction case management?

Answer: Personally introducing a client to the next provider by phone or in person before transfer

A warm handoff involves a direct, real-time introduction of the client to the next provider, reducing dropout and improving continuity of care.

In the context of case management, 'linkage' refers to:

Answer: Connecting a client to needed community resources and services

Linkage is a core case management function that involves actively connecting clients to community resources such as housing, medical care, and vocational services.