IMPORTANT NOTICE:
SECURE TEST BANK
Mastering Competencies In Family Therapy
Chapter 17: Document It: Progress Notes
1. These make up the “official” medical file, the formal medical record shared with other
medical professionals, clients (upon written request), and/or in response to subpoenas.
Third-party payers generally have detailed requirements for the content of these. What
are they?
a. Process notes
b. Progress notes
c. Psychotherapy notes
d. Payment notes
2. What detailed information are third-party payers looking for in progress notes?
a. Personal content of a client’s life
b. Details on the therapeutic conversation
c. The frequency and duration of symptoms
d. None of the above
3. The goal with progress notes is to maximize client privacy while simultaneously doing
which of the following?
a. Acknowledging the clients medical history
b. Documenting competent treatment that conforms to professional standards of care
c. Writing psychotherapy notes
d. Talking to third-party individuals to get a more holistic view of the client
4. Which of the following is an exception to the general principle of using minimal client
information in progress notes?
a. When interviewing a child
b. When stabilizing a crisis situations
c. When meeting a family sent by the court
d. When a client has an affair
5. Which of the following is NOT one of the common ingredients of progress notes
appropriate for meeting HIPAA guidelines and third-party payers?
a. Clients full name
b. Date, time, and length of session
c. Who attended the session
d. Client’s progress, including improvement or worsening of symptoms
6. Developed in response to early managed care requirements, DAP notes are one of the
more common formats for progress notes. DAP stands for which of the following?
a. Diagnosis, assessment, plan
b. Diagnosis, action, progress
c. Data, assessment, plan
d. Data, action, progress
7. SOAP notes are a second widespread format for progress notes. What does the S stand
for in the acronym?
a. Survey: using surveys to understand the client’s presenting problem
b. Summary: the therapist’s summary of the session
c. Symptoms: determining what diagnosis the symptoms meet
d. Subjective observations: the client’s narrative or reported symptoms
8. Progress notes should document the duration, frequency, and severity of symptoms
clients report. Which of the following is NOT a good example of this type of
documentation?
a. Client reports mild depressed mood most days (or five out of seven days).
b. Client reports one panic attack the past week, moderate severity.
c. Client reports feeling better since starting therapy.
d. Client reports decreased conflict with parents; two arguments past week.
9. Progress notes should clearly identify interventions the therapist used to help the client
address the problems identified in the treatment plan. Which of the following is an
example of a theory-specific intervention?
a. Identified steps to reduce depression over next week.
b. Created genogram to increase insight related to family drinking patterns.
c. Practiced alternatives to conflict.
d. Talked about fears with client.
10. A therapist notes, “Client receptive to reframe related to work issues; less receptive to
reframe of pattern related to relationship.” What is the therapist documenting?
a. Symptoms and progress
b. Interventions
c. Client response
d. Plan
11. “Client will bring parents to the next session.” This describes what?
a. Client response
b. Plan
c. Crisis Issues
d. Consultation
12. Jillian reported to her therapist that she had been cutting over the last week to cope with
stress related to her abuser’s release from prison. The therapist does a thorough
assessment of the client’s safety and creates a safety plan with Jillian for the next week
until her next scheduled appointment. How should the therapist document the crisis
issues?
a. With as little information as possible to protect Jillian’s privacy
b. In writing with clear details about the assessment process and specific actions
taken to ensure the safety of Jillian
c. The therapist should not document the crisis at all
d. None of the above
13. How should therapists sign their progress notes?
a. Electronically
b. With initials
c. By hand and including credentials
d. All of the above are acceptable
14. When is the best and most proper time to write progress notes?
a. During the session
b. Immediately after the session
c. 24 hours after the session
d. Right before the same client’s next session
15. What must the therapist do with any piece of paper that has identifying client information
on it, including phone message pads or calendars?
a. Save them in the client file.
b. Keep them out of sight.
c. Keep them in the locked file.
d. Throw them away.