Competency Quiz for Ethics of Clinical Documentation 4.19.24
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Questions and Answers

Which of the following statement is found in the NASW Code of Ethics on documentation?

  • "When providing clients with access to their records, social workers should take steps to protect the confidentiality of other individuals identified or discussed in such records."
  • “Social workers should not participate in, condone, or be associated with dishonesty, fraud, or deception.”
  • All of the above (correct)
  • None of the above
  • Which of the following is an example of unethical documentation?

  • Waiting days/weeks after the service before writing the note.
  • Billing a service for time actually spent with a client.
  • Completing another client's note during a session with a different client.
  • A & C (correct)
  • What unethical documentation practice was discussed during the Unethical Note Example portion of the training?

  • Therapy note that included information of another individual that was not the identified client. (correct)
  • Case Management note that included the incorrect date and time of the service provided.
  • Therapy note that had the incorrect service type selected.
  • Case management note that had the incorrect service type selected.
  • What are the names of the two HIPPA rules that were discussed during the training? _____ Rule and _____ Rule

    <p>Privacy and Security</p> Signup and view all the answers

    A psychotherapy note is documentation that tracks progress that is in the client record and contains a factual retelling of what happened in session and what improvements or barriers occurred during session.

    <p>False</p> Signup and view all the answers

    A progress note is documentation that is outside the client record and contains thoughts and observations.

    <p>False</p> Signup and view all the answers

    Civil money penalties for HIPPA violations is 100 dollars per violation to the Privacy Rule and does not exceed 25,000 dollars for the same violation.

    <p>True</p> Signup and view all the answers

    What are the three parts of the Fraud Triangle?

    <p>Pressure, Opportunity, and Rationalization</p> Signup and view all the answers

    What two laws were discussed regarding documentation fraud? ______ Act and _______ Law

    <p>False Claims and The Civil Monetary Penalty</p> Signup and view all the answers

    A potential risk of unethical documentation is burnout.

    <p>True</p> Signup and view all the answers

    The Golden Thread refers to the interconnectedness of documentation from Assessment to Treatment Plan to Progress notes and is an example of ethical documentation.

    <p>True</p> Signup and view all the answers

    Which of the following are skills to practice and implement to improve documentation?

    <p>All of the above</p> Signup and view all the answers

    If following the DMH reimbursement guidelines for session times, how many minutes would you have in between sessions to complete a note?

    <p>7</p> Signup and view all the answers

    What self-care skills were discussed to improve a clinician's Professional Efficacy?

    <p>Time management and Self-compassion</p> Signup and view all the answers

    Which of the following best describes, fraud?

    <p>Intentionally submitting false information to the Government to get money or a benefit.</p> Signup and view all the answers

    Study Notes

    NASW Code of Ethics on Documentation

    • The NASW Code of Ethics provides guidance on ethical documentation practices.

    Types of Documentation

    • A psychotherapy note is a type of documentation that tracks progress, contains a factual retelling of what happened in a session, and includes improvements or barriers that occurred during the session.
    • A progress note is not a type of documentation that is outside the client record, but rather, it is a part of the client record.

    HIPAA Rules

    • Two HIPAA rules were discussed during the training: the Privacy Rule and the __ Rule.
    • Civil money penalties for HIPAA violations can be up to $100 per violation to the Privacy Rule, with a maximum of $25,000 for the same violation.

    Fraud Triangle

    • The three parts of the Fraud Triangle are: __, __, and __.
    • Two laws were discussed regarding documentation fraud: the __ Act and the __ Law.

    Risks of Unethical Documentation

    • A potential risk of unethical documentation is burnout.

    Ethical Documentation

    • The Golden Thread refers to the interconnectedness of documentation from Assessment to Treatment Plan to Progress notes and is an example of ethical documentation.

    Improving Documentation

    • Skills to practice and implement to improve documentation include: __.
    • If following the DMH reimbursement guidelines for session times, clinicians would have __ minutes in between sessions to complete a note.

    Self-Care and Professional Efficacy

    • Self-care skills discussed to improve a clinician's Professional Efficacy include: __.

    Definition of Fraud

    • Fraud is best described as: __.

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