Multiple Choice
1. Writing and maintaining notes that are accurate, comprehensive, and up–to-date is a(n) ___________ obligation.
a.
Legal
b.
Professional
c.
Moral
d.
Ethical
2. The case manager, Enrique, meets with the rabbi of his client, Josh. This is known as which type of meeting?
a.
Collaborative
b.
Consensual
c.
Collateral
d.
Assessment
c
Labeling the Contact
3. What is the minimal requirement for a counselor as regards the monitoring of service delivery to his or her client?
a.
b.
c.
d.
c
4. A verbatim interaction between the case manager and the client and/or service-provider should be in which of the
following formats:
a.
In italics
b.
Enclosed in quotation marks
c.
Enclosed in asterisks
d.
Enclosed brackets
b
Documentation: Best Practice
5. Mannerisms, dress, attitudes, or expressions—all impressions of a client during a contact—reflect:
a.
The level of motivation
b.
The level of compliance with the program
c.
The client’s state of mind
d.
The ability of the client to conform to expectations
c
Documentation: Best Practice
6. Which of the following is considered an appropriate note following a contact?
a.
Stanley exhibited a highly repressed demeanor. Additionally, he appears to be exhibiting both transference and
projection of anger. He appears to be decompensating.
a
The Importance of Documentation
b.
Stanley appears to be fitting in well with the disabled people with whom he is working. He expressed a high
degree of satisfaction and pride.
c.
Stanley seemed discouraged, stating to me, I feel like less of a person than the other workers. His level of self-
esteem appears to be low.
d.
Stanley appears to be goal oriented. He is dressing professionally and adapting well to a work environment.
He now stands straighter and makes frequent eye contact.
7. Which of the following is an appropriate way to describe a client?
a.
Has a handicap
b.
Has a disability
c.
Has a birth defect
d.
Suffers from partial paralysis
b
Documentation: Best Practice
8. The use of black ink when filling out case notes and other forms is:
a.
Practical
b.
Mandated by the APA, ACA, and a host of other professional organizations
c.
Required by state and federal law
d.
Required by federal law
c
Government Requirements
9. When writing notes, it is considered essential to include evidence of _____________ between you and the referral
agency/service provider:
a.
Agreement
b.
Consensus
c.
Cooperation
d.
Unanimity
a
Provide Evidence of Agreement
10. Phil is not meeting the stated goals of his program. He is simply not achieving the levels of progress set forth in his
treatment plan. The correct procedure as pertains to the treatment plan is:
a.
Appending
b.
Supplementing
c.
Correcting
d.
Revising
d
Making Changes to the Plan
Subjective Short Answer
11. Name the 3 types of contact a case manager might have with a client.
Answers will vary
d
Documentation: Best Practice
12. Provide 4 examples of a client’s behavior that should be documented if it is significant.
13. Name 4 significant disabilities that need to documented.
14. List 5 words that could be construed as judgmental in documenting a contact with a client
15. What are 2 governmental requirements when documenting a contact with a client?
Essay
16. Write a contact note for the following: Maria came to see you today after a night of drinking with her friends. This is
the third time this has happened in 6 months. You discuss your concern with her. Maria refuted the idea that she has a
drinking problem and became hostile and loud. She left the appointment very angry and you are frustrated by her
behavior. No follow up was scheduled.
17. Correct the following case note: 07/15/15: Phil called the office today to complain about his services. Reports that he
has had little contact with his housing manager and his psychiatrist. Appears very agitated and angry. Will call both to
clarify what the issue is and see what they have to say about what has happened.