Evaluation and Documentation Flashcards
6 cards from real NCTRC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Evaluation and Documentation flashcards as text
A CTRS is leading an 8-week social skills group. After the fourth session, the CTRS reviews session notes and participant feedback, then modifies the activities for the remaining sessions to better meet the group's needs. This ongoing adjustment process is an example of what type of evaluation?
Answer: Formative evaluation
Formative evaluation is conducted during a program to monitor progress and make real-time adjustments to improve outcomes. By modifying activities mid-way through the program, the CTRS is using formative evaluation to enhance the group's effectiveness.
A CTRS is writing a SOAP note after a session. The CTRS writes: "Continue with weekly leisure education group to address goal #2. Will introduce client to community center resources next session." In which section of the SOAP note does this information belong?
Answer: Plan (P)
The Plan (P) section of a SOAP note outlines the future course of action based on the assessment. This includes specific interventions, frequency, and any new actions to be taken in subsequent sessions.
Which of the following is the PRIMARY purpose of completing a therapeutic recreation discharge summary?
Answer: To summarize the client's progress, current functioning, and provide recommendations for future leisure involvement.
The primary purpose of a discharge summary is to create a concise record of the client's treatment, including goals met, functional status at discharge, and specific recommendations to support their continued leisure lifestyle after leaving the facility. This ensures continuity of care.
A CTRS works in a facility that uses a Charting by Exception (CBE) documentation system. The CTRS would most likely write a progress note under which of the following circumstances?
Answer: The client refused to participate in the session and expressed a significant increase in anxiety.
Charting by Exception (CBE) is a documentation method where notes are only made when there is a deviation from the established norm or plan of care. A client's refusal to participate and a significant change in emotional state are exceptions that would require detailed documentation.
During a therapeutic recreation outing to a local museum, a client slips on a wet floor and falls, but is not injured. After ensuring the client is safe, what is the CTRS's primary documentation responsibility?
Answer: Complete a facility-specific incident report detailing the objective facts of the event.
An incident report is the formal tool for documenting any event that is not consistent with routine operations, such as a client fall, regardless of injury. Its primary purpose is for risk management, quality improvement, and to provide a factual, objective account of the incident, separate from the client's clinical progress notes.
A CTRS is tasked with evaluating the overall effectiveness of a 12-week wellness program after it has concluded. The CTRS compares participants' pre-program and post-program scores on a standardized quality of life assessment. This type of evaluation is known as:
Answer: Summative evaluation
Summative evaluation occurs at the end of a program to assess its overall effectiveness and determine if the intended outcomes were achieved. Comparing pre-test and post-test data is a common method for this type of evaluation, as it 'sums up' the program's impact.