evaluation and documentation Flashcards

(11 cards)

1
Q

What should a CTRS do first after the individual treatment has been created

A

document the plan in the client’s record

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2
Q

What is a component of the problem-oriented medical record (POMR)

A

discharge summary

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3
Q

What behavioural objective can be written for a client with a TBI to increase short term memory recall

A

The client will correctly restate that 75% of the directions given during the group

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4
Q

Why should a client be reassessed

A

to evaluate changes in status

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5
Q

Which variable does the criterion part of a behavioural objective identify?

A

indication that the objective has been achieved

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6
Q

Which form should be filled out if a client were to run away on a community outing

A

Incident report (agency dependent)

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7
Q

At what point should the TR initiate a transition plan

A

After the first few days in the program (agency dependent)

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8
Q

What is the most important benefit of writing progress notes

A

allows for clients to be evaluated

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9
Q

What is an example of risk management

A

monitoring and reviewing incident reports

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10
Q

Incident reports should be

A

brief and factual

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11
Q

What are client outcomes

A

results or changes in the client that come from participation and involvement in services

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