Documentation and Record Keeping
Documentation standards
Record contemporaneously, objectively, and behaviorally. Progress notes link to the treatment plan and include date, time, service, client response, interventions, progress, and plan. DAP (data, assessment, plan) and SOAP are common formats. Avoid labels (“manipulative,” “in denial”) and opinions without behavioral support. Corrections: draw a single line, date, initial, and state the reason-never erase, white out, or rewrite. Retain records per law and policy; release only with valid consent or legal requirement.
Traps
Late entries written as if contemporaneous, altered records, and subjective judgments are frequent errors. Sharing information with family, courts, or employers without proper authorization is a violation. A subpoena is not automatically a court order; consult and follow law. Also watch for notes that omit a failed contact, a referral, or a safety assessment.
Worked example
You realize you documented the wrong date. You draw one line through the error, write the correct date, add your initials and the date of correction, and note “date correction.” You do not create a new note that hides the change.
Rule of thumb
If it is not documented, it did not happen-and if it is not objective, it is not documentation.