Nr548 Week 6 Study Guide Rated A+

Documentation {Ans: Use the ten minutes following the 50-minute interview to record clinical findings -facilitates communication with other members of the healthcare team -provides information to insurance companies and third parties for billing and reimbursement -required to satisfy legal requirements and mitigate risk • Careful and thorough record-keeping is imperative in the event of litigation}All components of a clinical encounter should be documented including: {Ans: • chief complaint • referral source • history of present illness • current treatments including medications and therapies • past medical, family, social histories • review of systems • mental status examination • diagnosis • treatment plan}Assessment {Ans: -includes the diagnosis -concise and informative -A list of differential diagnoses may be included, but the initial diagnosis listed is the DSM-5 TR diagnosis.}Identifying Data {Ans: fairly long initial sentence that sets the stage for the entire evaluation -includes demographic descriptors of the client and the context of the referral • age, sex, marital status, and source of referral at a minimum • may include other information such as occupation, living situation, and presence of other family.}Implementing the Agreed-On Plan {Ans: likely fall into one or both of the following categories: -follow-up