CBHT Documentation and Record Keeping 3

Question 1

Which of the following best describes 'objective' documentation in a behavioral health record?

Accepted Answer

Observable, measurable, and verifiable information about the client's behavior

Answer

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?

Accepted Answer

The word 'seemed' is subjective; the BHT should describe specific observable behaviors instead

Answer

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?

Accepted Answer

Only when using abbreviations that are approved and standardized by the facility

Answer

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?

Accepted Answer

Draw a single line through the error, write the correction, and initial and date the correction

Answer

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?

Accepted Answer

Client will use a deep breathing technique for 5 minutes when feeling anxious, at least 3 times per week for 4 weeks

Answer

SMART goals are Specific, Measurable, Achievable, Relevant, and Time-bound; the third option defines a clear behavior, frequency, and timeline.

(CBHT) Certified Behavioral Health Technician Practice Test

(CBHT) Certified Behavioral Health Technician Practice Test

CBHT Documentation and Record Keeping 3