Documentation Formatting

An annotated visual of a clinical documentation template, including sections for needs, care plans, and problem identification, with a calm, professional background.

Mastering Documentation Formatting

Test your knowledge on proper documentation formatting in a clinical setting! This quiz will challenge your understanding of note-taking practices vital for effective care planning.

In this quiz, you will:

Answer multiple choice questions on document structure.
Demonstrate your understanding of care plans.
Write a rehab note incorporating essential elements.

8 Questions2 MinutesCreated by AnalyzingData251

What are the sections of the note format?

Problem, Needs Addressed, Next Steps/ Care Plan

Behavior, Intervention, plan

Needs Addressed, Next Plan/ Care Plan

Next Steps, Problem, Needs Addressed

What information is included in the Needs addressed section?

The needs addressed, interventions implemented, and the plan

Progress the client has made, interventions implemented, and next steps

Problem addressed, interventions implemented , client progress/ response

Interventions implemented, client progress, plan

Which answer best represent how a problem is written?

Client isolates daily due to depressed mood.

Client engages in physical aggression.

Client will decrease suicidal statements from 5 times a week to 0 times a week?

Client will decrease manic episodes.

Which answer reflects a Care Plan?

Services will continue to address Bipolar I Disorder.

TCM services will continue to address client's homelessness

Homelessness

Client will decrease abuse of methamphetamine from 6 times a week to 2 times a week.

Choose the best answer that describes the information in the Next Steps section.

Plan

Doctor's recommendation

Clin./CM and client's plan for next session, Care plan

Where the next session will be held.

Write a rehab note for a client with the following problem, Client engages in verbal aggression. Make sure to include all part of the note format.

Documentation Formatting

Mastering Documentation Formatting

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