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

Late entries are acceptable in behavioral health documentation as long as they are clearly labeled as late entries with both the current date/time and the actual time of the incident.

Question 2

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

Accepted Answer

SOAP notes

Answer

SOAP notes organize documentation into four sections: Subjective (client's statements), Objective (observable facts), Assessment (clinical interpretation), and Plan (next steps).

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

Thorough documentation of coping skill use includes the specific skill, the triggering situation, and measurable outcomes to track treatment effectiveness.

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

Under HIPAA, PHI includes any individually identifiable health information, including a person's name combined with their health condition or treatment details.

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

Incident reports must contain objective, factual information; subjective personal opinions about a client's character or traits are inappropriate and unprofessional.

(CBHT) Certified Behavioral Health Technician Practice Test

(CBHT) Certified Behavioral Health Technician Practice Test

CBHT Documentation and Record Keeping 2