CBHT Documentation and Record Keeping 3 — Questions and Answers
Question 1: Which of the following best describes 'objective' documentation in a behavioral health record?
- The clinician's interpretation of the client's emotional state
- Observable, measurable, and verifiable information about the client's behavior (Correct answer)
- A summary of the client's self-reported feelings
- A prediction of future client behavior
Correct answer: Observable, measurable, and verifiable information about the client's behavior
Objective documentation captures only what can be directly observed and measured, avoiding interpretation or inference about internal states.
Question 2: A BHT documents that a client 'seemed agitated.' What is wrong with this entry?
- Nothing; this is an appropriate objective description
- The word 'seemed' is subjective; the BHT should describe specific observable behaviors instead (Correct answer)
- The entry is too detailed for a behavioral health record
- The BHT should have used the client's own words instead
Correct answer: The word 'seemed' is subjective; the BHT should describe specific observable behaviors instead
Words like 'seemed' or 'appeared' introduce subjectivity; instead, the BHT should document specific observable behaviors such as 'client paced the room, raised voice, and clenched fists.'
Question 3: When is it appropriate to use abbreviations in clinical documentation?
- Only when the BHT is in a hurry
- Only when using abbreviations that are approved and standardized by the facility (Correct answer)
- At any time, as long as the BHT understands what they mean
- Never; all documentation must use full words
Correct answer: Only when using abbreviations that are approved and standardized by the facility
Abbreviations should only be used if they are on the facility's approved abbreviation list to prevent misinterpretation of clinical records.
Question 4: A BHT makes an error in a handwritten progress note. What is the correct way to correct it?
- Use correction fluid (white-out) to cover the error
- Scribble over the error so it is unreadable
- Draw a single line through the error, write the correction, and initial and date the correction (Correct answer)
- Tear out the page and rewrite the entire note
Correct answer: Draw a single line through the error, write the correction, and initial and date the correction
The correct method is to draw a single line through the error, write the correction nearby, and add initials and the date to maintain a clear and legal record.
Question 5: Which of the following is an example of a SMART goal as documented in a treatment plan?
- Client will feel better about themselves
- Client will improve coping skills
- Client will use a deep breathing technique for 5 minutes when feeling anxious, at least 3 times per week for 4 weeks (Correct answer)
- Client will try harder to manage emotions
Correct answer: Client will use a deep breathing technique for 5 minutes when feeling anxious, at least 3 times per week for 4 weeks
SMART goals are Specific, Measurable, Achievable, Relevant, and Time-bound; the third option defines a clear behavior, frequency, and timeline.
Question 6: How long are behavioral health records typically required to be retained after the last date of service for an adult client?
- 1 year
- 3 years
- 7 years or as required by state law (Correct answer)
- Records can be destroyed immediately after discharge
Correct answer: 7 years or as required by state law
Most states require behavioral health records to be retained for at least 7 years after the last service date for adult clients, though specific requirements vary by state.
Question 7: A BHT observes that a client refused their scheduled group therapy session. How should this be documented?
- Do not document the refusal since no service was rendered
- Document only that the client was absent
- Document that the client refused the session, the reason given (if any), and any follow-up actions taken (Correct answer)
- Document it as a behavioral incident requiring a full incident report
Correct answer: Document that the client refused the session, the reason given (if any), and any follow-up actions taken
Refusals of service must be documented completely, including the fact of refusal, any stated reason, and what actions staff took in response.
CBHT Documentation and Record Keeping 3
Which of the following best describes 'objective' documentation in a behavioral health record?