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Dq1 What are the major requirements that must be made for documentation of a new client and an ongoing client? What are the possible consequences if a counselor does not follow required record-keeping practices?   DQ 2 What are the legal standards for clinical documentation in the state in which you plan to practice? How are they different than federal regulations? How are they similar?   Assignment 1   Complete the Standard Abbreviations Worksheet. APA style is not required, but solid academic writing is expected.     PCN-485 Standard Abbreviations for Counselors/Behavioral Health ACA Adult Children of Alcoholics ADD Attention Deficit Disorder ADHD Attention Deficit Hyperactivity Disorder AMA Against Medical Advice Appt.     Appointment B.P. Blood Pressure (B) Brother C With CD Chemical Dependency C.N.S. Central Nervous System Ct. Client C/o Complains of DUI Driving under the influence DSM-5 Diagnostic and Statistical Manual of Mental Disorders-5th ed. DWI Driving while intoxicated Dx Diagnosis ECT Electroconvulsive therapy E.D. Emergency department E.R. Emergency room ETOH Ethel alcohol Eval Evaluation = equal <  Less than >  Greater than (F) Father Hx History I.Q. Intelligence quotient I.V. Intravenously Lbs. Pounds L.S.D Lysergic Acid Diethylamide Meds. Medication (M) Mother MSE Mental Status Exam Neg. negative – negative n/a not applicable # number n/s no show PCP Phencyclidine Pt. Patient P.O. Probation officer + Plus R/O rule out (S) Sister TD Tardive Dyskinesia THC Tetrahydrocannibinol Tx Treatment               Standard     Abbreviations Worksheet   Directions:  Edit the following clinical note using standard abbreviations where applicable.  Use the “Standard Abbreviations for Counselors” resource to guide you through completion of the worksheet.   Clinical Note:   Today, Joe came into the office for his regularly scheduled counseling appointment.  Today’s visit was to review his assessment by the resident psychiatrist to explore what his diagnosis was.  The psychiatrist used the Diagnostic and Statistical Manual of Mental Disorders-5th Edition to review the symptoms Joe was experiencing.  Since Joe was arrested three weeks ago for driving under the influence, it was determined that he could be suffering from substance use issues. Client reports he is not currently on any medication, but is complaining of symptoms of depression and anxiety, as well as craving a drink.   After obtaining a release of information from his probation officer, it was learned that Joe is facing charges of driving under the influence, and has a prior history of this behavior.  He has been arrested twice before.  In his most recent stay in jail, he was talking about how depressed he was, and the jail called the counselor.  That counselor referred Joe to the psychiatrist. Joe disclosed that on a recent trip to the emergency room, after he had a panic attack, he decided that it was time for a change. At first, he thought his blood pressure was too high and he was having a heart attack.  Against medical advice, Joe left the emergency room without receiving any medication for his anxiety.  He left with his brother and decided to call the psychiatrist.   After reviewing the diagnosis made by the psychiatrist, and explaining the purposes of the Diagnostic and Statistical Manual of Mental Disorders-5th Revision, Joe decided to schedule another appointment to obtain a mental status exam, as well as schedule a treatment planning session.    Sarah Smith, , LPC                                                         October 29, 2013 Case Manager Signature                                                                                               Date                       Assignment 2   Complete the “Client Intake and HIPAA Worksheet.” Client Intake and HIPAA Worksheet   Part 1:   1.      Imagine that you are a case manager working with a new client.  In an answer of 250-500 words, describe the forms that you would use to intake the client.  Include the purpose of each form in your answer.  Also, include at least one scholarly reference to support your response.         2.      Conduct an Internet search for three different intake forms. Compare and contrast the forms found during your search. How are they similar? How are they different? What is the benefit of having a detailed intake form?       Part 2:   Scenario: James’s wife is waiting for him in the lobby of the agency while he is in session with his case manager.  In the waiting room, there are several other clients and professionals waiting to be seen by their case manager or waiting for a meeting to begin.  When the case manager comes out of her office with James, his wife approaches her, requesting information about James, his medication, and his diagnosis.  The other people in the waiting room are staring at her, then at James, then at the case manager expecting something to happen.  James’s wife wants to know if he can stop taking the Xanax, because it makes him act “funny.” Plus, she said that he was denied his medical card because she makes too much money and wants to know if the case manager can provide the service for no cost.    Imagine that you are James’s case manager.  In an answer of 250-500 words, describe how you would handle this situation to ensure that you are complying with confidentiality and HIPAA regulations.  Include at least one scholarly reference to support your respon

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