Documentation and Record Keeping
What the candidate must know
Records must be timely, accurate, objective, and sufficient to justify services and support continuity of care. Know common formats: progress notes, treatment plans, intake assessments, discharge summaries, and release-of-information forms.
Understand what belongs in a record: presenting concerns, observations, interventions, client response, plan, and risk status. Know that records are legal documents that may be subpoenaed, and that clients generally have rights to access their records subject to exceptions (for example, when access could cause harm).
Traps in questions
- Recording opinions or labels as fact rather than describing observable behavior.
- Including unnecessary sensitive detail that increases risk if disclosed.
- Backdating or altering records improperly.
- Omitting risk assessment, which is a frequent source of liability.
Rule of thumb
Write as if the client and a court could read the note. Prefer behavior descriptions over judgments, and always document risk assessment and the rationale for decisions.
Worked example
Instead of "client was manipulative and difficult," write "client raised voice twice and left the session early after discussing a scheduling conflict; I offered to reschedule and documented the client's response."