Assessment, planning and documentation
Assessment, planning and documentation
The exam tests strengths-based, person-centered assessment and defensible documentation.
Core rules
- Assess strengths, preferences, culture, safety, and barriers, not just deficits.
- Goals are collaborative and SMART: specific, measurable, achievable, relevant, and time-bound. The client’s words should appear.
- Documentation is contemporaneous, objective, and behavioral. Record what was observed and said, the intervention used, the client’s response, and next steps.
- Protect privacy: use secure systems, share the minimum necessary information, and avoid personal devices.
- Correct errors with a dated addendum; never alter a signed note.
Worked example
Two notes for the same visit: A: “Client was resistant and manipulative; refused group.” B: “Client declined group, stating ‘I don’t feel safe there.’ Explored concerns; client identified a smaller women’s group as acceptable. Sent referral; will follow up Thursday.” Reasoning: B is observable, avoids labels, and documents client voice, choice, and action. A is judgmental, vague, and legally risky.
Traps that cost marks
“Client was noncompliant” states a judgment; describe the behavior instead. Copy-paste notes create false records. Goals written by staff without client input are not person-centered. Late notes lose accuracy. Including irrelevant family details violates minimum necessary. Sharing screenshots breaches privacy.