NCTRC Individualized Plan of Care 5 — Questions and Answers
Question 1: Which of the following scenarios BEST demonstrates person-first language in an individualized plan of care?
- The autistic client will attend two group sessions per week
- The client with autism will attend two group sessions per week (Correct answer)
- The special needs client will participate in structured activities
- The disabled individual will engage in adaptive recreation
Correct answer: The client with autism will attend two group sessions per week
Person-first language places the individual before their diagnosis or disability, reflecting respect and dignity in documentation.
Question 2: An interdisciplinary team disagrees with a TR goal a CTRS has included in the individualized plan of care. The CTRS should:
- Remove the goal immediately without discussion
- Advocate for the goal by explaining its therapeutic rationale to the team (Correct answer)
- Defer all TR goals to the team's discretion
- Document the disagreement and continue without modification
Correct answer: Advocate for the goal by explaining its therapeutic rationale to the team
CTRSs are responsible for advocating for TR's role by clearly articulating the clinical rationale for goals to the interdisciplinary team.
Question 3: Which type of assessment data is MOST directly used to establish baseline information in an individualized plan of care?
- Peer observations from group sessions
- Standardized functional assessment scores obtained during intake (Correct answer)
- Family anecdotes reported informally
- Insurance authorization documents
Correct answer: Standardized functional assessment scores obtained during intake
Standardized functional assessments conducted at intake provide objective baseline data against which goal progress can be measured.
Question 4: A CTRS is writing a plan of care for a client in an acute psychiatric setting. Goals should reflect the client's expected:
- Long-term community reintegration over 12 months
- Functional gains achievable within the brief inpatient stay (Correct answer)
- Lifetime leisure interests regardless of current status
- Compliance with all facility programming
Correct answer: Functional gains achievable within the brief inpatient stay
In acute settings, goals must be realistic and achievable within the short length of stay, focusing on stabilization and immediate functional needs.
Question 5: Which of the following is an example of a LONG-TERM goal appropriate for an individualized plan of care?
- Client will identify one coping leisure activity by end of week 1
- Client will independently access community recreation resources within 90 days of discharge (Correct answer)
- Client will attend today's group session with verbal prompting
- Client will list two leisure interests during the initial assessment interview
Correct answer: Client will independently access community recreation resources within 90 days of discharge
Long-term goals describe the ultimate functional outcome expected by the end of treatment or a defined extended timeframe, such as community reintegration.
Question 6: When a client is unable to participate in the goal-setting process due to cognitive impairment, the CTRS should:
- Skip the individualized plan of care entirely
- Develop goals based solely on the CTRS's clinical judgment without input
- Involve the client's family or legal guardian as proxy in the planning process (Correct answer)
- Use the same generic goals applied to all cognitively impaired clients
Correct answer: Involve the client's family or legal guardian as proxy in the planning process
When clients cannot self-advocate, involving family members or legal guardians ensures the plan remains individualized and reflects the client's values and preferences.
Question 7: Progress notes related to an individualized plan of care should be written to:
- Summarize all recreational activities the client attended
- Objectively document the client's response to interventions in relation to stated goals (Correct answer)
- Record the CTRS's subjective impressions of the client's personality
- List upcoming activities scheduled for the next month
Correct answer: Objectively document the client's response to interventions in relation to stated goals
Progress notes must link observed client behavior and functional gains directly to the goals outlined in the individualized plan of care.
NCTRC Individualized Plan of Care 5
Which of the following scenarios BEST demonstrates person-first language in an individualized plan of care?