PTSD Clinical Documentation & Records 3 — Questions and Answers
Question 1: A PTSD client's employer requests records to verify disability. Which action is most appropriate?
- Send all records immediately as employment records are public
- Obtain a specific written authorization before releasing any records (Correct answer)
- Provide a verbal summary to the employer by phone
- Release only medication records but not therapy notes
Correct answer: Obtain a specific written authorization before releasing any records
A specific written authorization from the client must be obtained before releasing any records to an employer.
Question 2: In PTSD documentation, what does a GAF or WHODAS score primarily provide?
- Trauma exposure severity rating
- Quantifiable measure of functional impairment (Correct answer)
- DSM-5 diagnostic code
- Insurance billing classification
Correct answer: Quantifiable measure of functional impairment
The GAF and WHODAS provide quantifiable measures of functional impairment useful for tracking treatment progress.
Question 3: Which documentation practice best supports continuity of care when a PTSD client transfers to a new provider?
- Verbal handoff between clinicians
- Comprehensive discharge or transfer summary with current symptom status and treatment history (Correct answer)
- Forwarding raw session recordings
- Sending only the intake assessment
Correct answer: Comprehensive discharge or transfer summary with current symptom status and treatment history
A comprehensive transfer summary ensures the receiving provider has current symptom status and treatment history for safe continuity of care.
Question 4: When a minor presents for PTSD treatment following abuse, who must sign the initial consent for treatment in most US states?
- The minor, if they appear mature
- A parent or legal guardian (Correct answer)
- The referring school counselor
- The child's primary care physician
Correct answer: A parent or legal guardian
In most US states, a parent or legal guardian must provide written consent for a minor's mental health treatment.
Question 5: How should a clinician document a PTSD client's refusal of a recommended treatment modality?
- Omit it to avoid liability
- Note the refusal, alternatives offered, client's stated reasons, and risks discussed (Correct answer)
- Document it only if the client signs a waiver
- Record it in a separate file not shared with the client
Correct answer: Note the refusal, alternatives offered, client's stated reasons, and risks discussed
Documenting refusal with alternatives offered, client reasons, and risks discussed creates a legally defensible record of informed decision-making.
Question 6: Which scenario represents an appropriate use of a collateral contact note in PTSD care?
- Documenting a conversation with the client's employer about job performance
- Recording a call with a family member consented by the client to coordinate safety planning (Correct answer)
- Noting unsolicited information from a neighbor
- Filing a report from the client's attorney
Correct answer: Recording a call with a family member consented by the client to coordinate safety planning
Collateral contact notes should document only consented contacts, such as family coordination for safety planning.
Question 7: What is the primary purpose of a treatment plan in PTSD documentation?
- To satisfy billing requirements only
- To establish measurable goals, interventions, and timelines guiding clinical care (Correct answer)
- To record the client's personal trauma history in detail
- To communicate the diagnosis to the client's insurer
Correct answer: To establish measurable goals, interventions, and timelines guiding clinical care
A treatment plan establishes measurable goals, interventions, and timelines that guide and document the course of clinical care.
PTSD Clinical Documentation & Records 3
A PTSD client's employer requests records to verify disability.
Which action is most appropriate?