Documentation and Record Keeping
What to know
Records must be timely, accurate, objective, and sufficient to justify care and support continuity. Know the standard elements: identifying data, informed consent, assessment, diagnosis, treatment plan, progress notes, and termination summary. Understand common note formats (SOAP, DAP, BIRP) and what each section should contain. Documentation should capture clinical reasoning, risk assessment, consultations, disclosures, and client response to intervention - while avoiding speculation, pejorative language, and unnecessary detail. Know rules for correcting errors (never alter; add an addendum), retention periods, secure storage, and release procedures. Understand that records may be read by clients, courts, and auditors.
Traps in questions
- Writing subjective judgments as fact or including irrelevant sensitive details.
- Backdating or altering notes; correct only via dated addendum.
- Omitting risk assessment, safety planning, or consultation from the record.
- Recording more than necessary, violating minimum-necessary principles.
Rule of thumb
If it is not documented, it did not happen. Write as if the client and a court will read it: objective, respectful, and complete.
Worked example: After a risk assessment, the note should record the questions asked, the client's responses, protective factors, the safety plan, and the follow-up date - not merely "client stable."