CCEA Skills Assessment flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

DSM-5-TR

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision; provides standardized criteria for mental health diagnoses used in clinical assessment and billing.

Differential diagnosis

Process of distinguishing a disorder from others with similar symptoms by comparing clinical features, onset, course, and ruling out medical or substance causes.

Mental status examination

Structured assessment of appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment.

Sensitivity and specificity

Sensitivity is the proportion of true positives correctly identified; specificity is the proportion of true negatives correctly identified by a test.

Cultural Formulation Interview

DSM-5 tool using 16 questions to assess cultural identity, illness explanations, stressors, and clinician-client relationship to improve diagnostic accuracy.

SMART goals

Treatment planning criteria: Specific, Measurable, Achievable, Relevant, and Time-bound; each goal includes baseline and target date for evaluation.

Cognitive behavioral therapy

Structured psychotherapy targeting maladaptive thoughts and behaviors; techniques include cognitive restructuring, behavioral activation, and exposure.

Exposure therapy

Evidence-based intervention for anxiety disorders involving graded, repeated, and prolonged contact with feared stimuli while preventing escape or avoidance behaviors.

Motivational interviewing

Client-centered counseling style using open questions, affirmations, reflections, and summaries to strengthen intrinsic motivation and resolve ambivalence.

Trauma-informed care

Service approach grounded in safety, trustworthiness, peer support, collaboration, empowerment, and cultural humility to avoid retraumatization.

Informed consent

Process of providing information about treatment nature, risks, benefits, alternatives, confidentiality limits, and fees, then documenting voluntary agreement.

Tarasoff duty

Legal obligation in many jurisdictions to protect an identifiable third party from a client’s serious threat of violence, typically by warning or notifying authorities.

Mandatory reporting

Legal requirement for clinicians to report suspected child abuse, elder abuse, or dependent adult abuse to designated authorities per state law.

Boundary violation

Exploitative or harmful crossing of professional limits that damages the therapeutic relationship, such as sexual contact or financial dual relationships.

Scope of competence

Range of practice for which a clinician has adequate training, supervision, and experience; outside this range, referral or consultation is required.

Active listening

Communication technique using paraphrasing, reflecting feelings, summarizing, and open-ended questions to confirm and demonstrate understanding of the client.

SBAR

Structured communication tool: Situation, Background, Assessment, Recommendation; used for handoffs and interprofessional team communication.

Therapeutic alliance

Bordin’s model comprising agreement on goals, agreement on tasks, and emotional bond between clinician and client; predicts treatment outcome.

Teach-back method

Health literacy technique where the client explains information in their own words to verify comprehension and correct misunderstandings.

Cultural humility

Lifelong self-reflection, redressing power imbalances, and institutional accountability in cross-cultural communication and care.

Evidence hierarchy

Ranking of study designs by strength of evidence: systematic reviews and meta-analyses highest, then randomized trials, cohort, case-control, case reports, expert opinion.

PICO

Framework for clinical questions: Population, Intervention, Comparison, Outcome; guides literature search and critical appraisal.

Number needed to treat

NNT = 1 / absolute risk reduction; number of patients who must receive an intervention for one additional beneficial outcome.

Internal validity

Degree to which study results are caused by the intervention rather than bias or confounding; enhanced by randomization and blinding.

Evidence-based practice

Integration of best available research evidence, clinical expertise, and patient values and preferences in clinical decision-making.

Warm handoff

Direct connection of a client to another provider through in-person introduction or joint call; improves referral engagement and continuity of care.

Closed-loop communication

Communication protocol where sender initiates message, receiver acknowledges, and sender confirms understanding to prevent errors.

Referral criteria

Conditions prompting referral: needs exceed clinician competence, specialized assessment required, or conflict of interest impairs objectivity.

Role clarification

Interprofessional competency of explicitly stating each team member’s scope of practice, responsibilities, and limitations to coordinate care.

HIPAA Security Rule

Federal regulation requiring administrative, physical, and technical safeguards to protect electronic protected health information.

Minimum necessary standard

HIPAA principle requiring use, disclosure, or request of only the minimum protected health information needed for a given purpose.

Record retention

Legal requirement to keep clinical records for a specified period; often at least 7 years after last service for adults, longer for minors per state law.