Documentation and Record Keeping Flashcards
7 cards from real CBHT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation and Record Keeping flashcards as text
Which of the following best describes 'objective' documentation in a behavioral health record?
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.
A BHT documents that a client 'seemed agitated.' What is wrong with this entry?
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.'
When is it appropriate to use abbreviations in clinical documentation?
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.
A BHT makes an error in a handwritten progress note. What is the correct way to correct it?
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.
Which of the following is an example of a SMART goal as documented in a treatment plan?
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.
How long are behavioral health records typically required to be retained after the last date of service for an adult client?
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.
A BHT observes that a client refused their scheduled group therapy session. How should this be documented?
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.