PTSD Clinical Documentation & Records 3

Question 1

A PTSD client's employer requests records to verify disability. Which action is most appropriate?

Accepted Answer

Obtain a specific written authorization before releasing any records

Answer

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?

Accepted Answer

Quantifiable measure of functional impairment

Answer

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?

Accepted Answer

Comprehensive discharge or transfer summary with current symptom status and treatment history

Answer

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?

Accepted Answer

A parent or legal guardian

Answer

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?

Accepted Answer

Note the refusal, alternatives offered, client's stated reasons, and risks discussed

Answer

Documenting refusal with alternatives offered, client reasons, and risks discussed creates a legally defensible record of informed decision-making.

(PTSD) Post Traumatic Stress Disorder Certification Practice Test