Communication and Documentation
Effective communication and accurate documentation are core case management competencies. This domain tests whether you can choose the right communication approach and document in a way that is complete, objective, and defensible.
Concepts to master
- Therapeutic communication: active listening, open-ended questions, reflection, clarification, and empathy.
- Barriers to communication: jargon, sensory deficits, cognitive impairment, language, and emotional distress.
- Documentation standards: objective, timely, accurate, complete, and confidential; written in the client's record contemporaneously.
- SBAR: Situation, Background, Assessment, Recommendation - a structured handoff tool.
- Informed consent documentation and confidentiality safeguards in records.
- Interprofessional communication: clear, respectful, role-appropriate exchange.
Traps in questions
- Subjective language in documentation. "Client was difficult" is inappropriate; document observable facts.
- Late or altered records. Never backdate or alter a record improperly.
- Closed or leading questions. These shut down disclosure; open-ended questions invite information.
- Skipping handoff structure. SBAR prevents omissions during transitions.
Worked example / rule of thumb
During a handoff, organize information as Situation → Background → Assessment → Recommendation. In documentation, write what you observed and did, not judgments. Rule of thumb: if it wasn't documented, it wasn't done - and document facts, not opinions.