Documentation and Record Keeping
Documentation is the legal and clinical record of care: intake forms, assessments, treatment plans, progress notes, releases, and discharge summaries. Candidates should understand the purposes-continuity of care, legal protection, quality improvement, billing-and the standards of accuracy, timeliness, objectivity, and confidentiality. Progress notes should reflect the client's status, interventions used, the client's response, and the plan, often captured by formats like SOAP or DAP. Know the difference between objective observations and subjective impressions, and the requirement to document significant events (e.g., risk disclosures, referrals, missed sessions).
Traps: writing opinions as facts; backdating or altering records improperly; omitting risk disclosures; including information from other clients; and failing to document consent or releases. Also know retention and access rules-clients generally have rights to their records with limited exceptions-and that corrections should be made as addenda, not by erasing entries.
Rule of thumb: if it isn't documented, it didn't happen. Write notes as if a colleague will rely on them and a court may read them-objective, dated, signed, and free of speculation.
Worked example: A client discloses suicidal ideation. The note should record the disclosure, the risk assessment performed, actions taken (safety plan, referral, emergency contact), and follow-up-not just 'client seemed down.'