CCEA Skills Assessment cheat sheet

DSM-5-TR diagnostic criteria require meeting all listed symptom thresholds and causing clinically significant distress or impairment for most disorders.

Differential diagnosis rule: rule out medical conditions (e.g., hypothyroidism for depression) and substance/medication-induced causes before assigning a primary psychiatric diagnosis.

Standardized screening tools: PHQ-9 (depression), GAD-7 (anxiety), AUDIT (alcohol), and C-SSRS (suicide risk) have validated cutoffs and should be followed by clinical interview.

Mental status examination components: appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment.

Cultural Formulation Interview (CFI) in DSM-5 assesses cultural identity, illness explanations, stressors, and clinician-patient relationship.

Reliability = consistency of a measure; validity = accuracy in measuring the intended construct; sensitivity = true positive rate; specificity = true negative rate.

Diagnostic overshadowing occurs when physical symptoms are attributed to a psychiatric condition, leading to missed medical diagnoses.

For children and adolescents, use multi-informant assessment (parent, teacher, self) and developmental norms to avoid over- or under-identification.

SMART goal criteria: Specific, Measurable, Achievable, Relevant, and Time-bound; each treatment plan goal should include a baseline and target date.

Cognitive Behavioral Therapy (CBT) model: thoughts → feelings → behaviors; interventions include cognitive restructuring, behavioral activation, and exposure.

Exposure therapy for anxiety disorders uses graded, repeated, and prolonged exposure to feared stimuli without escape behaviors to extinguish conditioned fear.

Motivational interviewing (MI) principles: express empathy, develop discrepancy, roll with resistance, and support self-efficacy.

Crisis intervention steps: ensure safety, establish rapport, identify the problem, explore coping, develop an action plan, and follow up.

Medication-assisted treatment (MAT) for opioid use disorder includes buprenorphine, methadone, or naltrexone combined with behavioral therapy.

Trauma-informed care principles: safety, trustworthiness, peer support, collaboration, empowerment, and cultural humility.

Treatment plan review should occur at least every 90 days or when significant changes in functioning occur, documenting progress toward goals.

Informed consent must include nature of treatment, risks, benefits, alternatives, right to withdraw, confidentiality limits, and fees; document consent in the record.

Mandatory reporting: clinicians must report suspected child abuse, elder abuse, and dependent adult abuse to designated authorities per state law.

Tarasoff duty to protect: when a client poses a serious threat to an identifiable victim, clinicians must take reasonable steps (warn, protect, or notify police) as defined by jurisdiction.

Boundary crossings become boundary violations when they exploit the client or harm the therapeutic relationship; avoid dual relationships that impair objectivity.

HIPAA Privacy Rule permits disclosure for treatment, payment, and health care operations; other disclosures require authorization unless an exception applies.

Ethical decision-making model: identify the problem, consult ethical codes and laws, consider stakeholders, evaluate options, choose and act, then document and review.

Competence: practice within scope of training and experience; seek supervision or refer when a case falls outside one’s competence.

Confidentiality with minors: legal guardians generally have access to records, but state law may allow minors to consent to certain services (e.g., substance use, mental health).

Active listening techniques: paraphrasing, reflecting feelings, summarizing, and asking open-ended questions to confirm understanding.

Motivational interviewing OARS: Open questions, Affirmations, Reflections, and Summaries; reflections should outnumber questions.

Therapeutic alliance components (Bordin): agreement on goals, agreement on tasks, and emotional bond.

SBAR communication: Situation, Background, Assessment, Recommendation-used for structured handoffs and interprofessional communication.

Teach-back method: ask the client to explain information in their own words to verify comprehension and address health literacy.

Conflict resolution steps: identify shared goals, separate people from the problem, focus on interests, generate options, and agree on objective criteria.

Cultural humility: lifelong self-reflection, redressing power imbalances, and institutional accountability in cross-cultural communication.

Nonverbal communication (eye contact, posture, tone) should be adapted to cultural norms and client comfort, not assumed universal.

Evidence hierarchy: systematic reviews/meta-analyses > randomized controlled trials > cohort studies > case-control studies > case reports > expert opinion.

PICO framework: Population, Intervention, Comparison, Outcome-used to formulate answerable clinical questions.

Effect size measures: Cohen’s d (0.2 small, 0.5 medium, 0.8 large); number needed to treat (NNT) = 1/absolute risk reduction.

Statistical significance (p < .05) does not equal clinical significance; consider confidence intervals and minimal clinically important difference (MCID).

Bias types: selection, performance, detection, attrition, and reporting bias; randomization and blinding reduce these risks.

Internal validity = degree to which results are due to the intervention; external validity = generalizability to other populations and settings.

Critical appraisal of a therapy study includes random sequence generation, allocation concealment, blinding, intention-to-treat analysis, and completeness of follow-up.

Evidence-based practice integrates best available research, clinical expertise, and patient values and preferences (Sackett et al.).

Role clarification: each team member’s scope of practice, responsibilities, and limitations should be explicitly stated at team formation.

Warm handoff: directly connecting a client to another provider (e.g., in-person introduction or joint call) improves engagement compared to a referral list.

Referral criteria: refer when the client’s needs exceed the clinician’s competence, when specialized assessment is required, or when there is a conflict of interest.

Closed-loop communication: sender initiates message, receiver acknowledges, and sender confirms understanding to prevent errors.

Interprofessional team meetings should include shared goal setting, information sharing with consent, and documentation of decisions.

Care coordination includes medication reconciliation, sharing of treatment plans (with consent), and follow-up on referrals.

When referring, provide the client with reason for referral, contact information, and ensure transfer of relevant records with signed authorization.

Collaboration with primary care improves outcomes for co-occurring mental and physical health conditions through integrated behavioral health models.

HIPAA Security Rule requires administrative, physical, and technical safeguards for electronic protected health information (ePHI).

Minimum necessary standard: use, disclose, or request only the minimum PHI needed for the purpose.

Record retention: follow state and federal requirements; for adults, retain records at least 7 years after last service; for minors, often until age of majority plus several years (check jurisdiction).

Progress notes should include date, time, service provided, client’s response, plan, and signature/credentials of the provider.

Corrections to records: never alter or delete original entries; add an addendum with date, time, and reason for the change.

Breach notification: notify affected individuals without unreasonable delay and no later than 60 days after discovery; notify HHS and media if >500 individuals affected.

Release of information requires a signed authorization specifying the information to be disclosed, recipient, purpose, expiration date, and right to revoke.

Mandated reporting documentation should include the date, time, parties notified, and actions taken, while maintaining confidentiality of the report.