CBHT Documentation and Record Keeping 2

Question 1

A BHT notices a client had a behavioral incident but forgot to document it immediately. What is the best course of action?

Accepted Answer

Write a late entry note clearly labeled with current date and time and the actual time of the incident

Answer

Ignore it since too much time has passed

Answer

Ask a coworker to backdate the entry

Answer

Wait until the next shift to see if it happens again

Question 2

Which type of progress note format requires the clinician to document Subjective, Objective, Assessment, and Plan information?

Accepted Answer

SOAP notes

Answer

DAP notes

Answer

BIRP notes

Answer

STAR notes

Question 3

When documenting a client's use of a coping skill, the BHT should record which of the following?

Accepted Answer

The specific skill used, the situation that triggered it, and the observable outcome

Answer

Only that the coping skill was used

Answer

The BHT's opinion on whether the skill will work long-term

Answer

Only the client's verbal description of how they felt

Question 4

Which of the following is considered protected health information (PHI) under HIPAA?

Accepted Answer

A client's name combined with their diagnosis

Answer

General statistics about behavioral health diagnoses

Answer

Anonymized aggregate treatment data

Answer

Educational materials about mental health disorders

Question 5

A BHT is completing an incident report after a client fell during group therapy. Which detail is LEAST important to include?

Accepted Answer

The BHT's personal opinion about why the client is clumsy

Answer

The exact time and location of the fall

Answer

The names of witnesses present

Answer

The immediate care provided after the fall

Question 6

What does the term 'countersignature' mean in behavioral health documentation?

Accepted Answer

A supervisor's signature indicating review and approval of a clinician's documentation

Answer

A client's signature on a treatment consent form

Answer

A duplicate copy of a progress note

Answer

A client's refusal to sign a document

Question 7

If a client requests a copy of their medical records, a BHT should:

Accepted Answer

Direct the client to the appropriate staff member or follow the facility's records release procedure

Answer

Provide the records immediately without any verification

Answer

Deny the request since clients cannot access their own records

Answer

Share the records only if the client's family also approves