The Basics of Documentation
What is the difference between objective and subjective information in documentation?
Objective: Observable facts (e.g., client pacing). Subjective: Client's reported experiences (e.g., "I feel anxious").
In SOAP notes, what does ‘S’ stand for and explain what a subjective paragraph is?
Subjective – Client's self-report, symptoms, or concerns.
What three main components make up a treatment plan?
Goals, objective, and intervention.
What is the primary purpose of utilization review?
To justify medical necessity and ensure appropriate level of care.
If a client expresses suicidal ideation, what is the first documentation step you should take?
Document a risk assessment, safety plan, and any follow-up actions taken.
What document must be completed before providing treatment?
Informed Consent
What do SOAP and PIRP stand for?
SOAP: Subjective, Objective, Assessment, Plan.
PIRP: Problem, Intervention, Response, Plan.
How often should treatment plans be updated for both MH and SUD?
MH- every 90 days or as clinically necessary
SUD- every 30 days or as clinically necessary
What does “level of care” refer to in mental health treatment?
The intensity of services required, such as outpatient, IOP, PHP, or inpatient care.
What should you do if you make a documentation error (besides contact supervisor)?
Use an addendum, date it, and explain the correction without deleting original content.
How soon after a session should a progress note be completed?
Within 24 hours.
What does the ‘I’ stand for in PIRP notes and give a sentence that would be included in this paragraph?
Intervention
What model is typically used to ensure treatment goals are clear and measurable?
SMART Goals – Specific, Measurable, Achievable, Relevant, Time-bound.
Why is it important to document justification for the level of care?
To ensure proper treatment placement, support insurance claims, and prevent denials.
What are two red flags that could trigger an audit of clinical documentation?
Overuse of copy-pasting, vague or missing progress notes, inconsistent diagnosis and treatment alignment, incorrect dates and timeframes, backdated records, lack of medical necessity justification, etc.
Name at least three elements that must be included in a comprehensive mental health assessment.
Client history, presenting problem, mental status exam, diagnosis, risk factors, and treatment recommendations.
Give an example of an appropriate "Objective" statement in a progress note.
Ex- "Client arrived on time, maintained good eye contact, and engaged actively in the session."
What is a common mistake therapists make when writing treatment goals?
Making them too vague or broad instead of specific, measurable, and time-bound (SMART).
How often should the utilization review be completed?
As often as the treatment plan is completed. Every 30 days for SUD and 90 days for MH unless it's clinically necessary sooner.
True or False: Records may be given to immediate family members only, without an ROI.
False. An ROI is needed for anyone anytime. (parents and guardians exempt)
True or False: Clinicians should include every single detail the client shares in their documentation.
False – Only clinically relevant and necessary details should be documented while maintaining privacy.
What’s the difference between an "Assessment" paragraph and mental status exam information?
The assessment paragraph is a clinical summary of the client’s progress, symptom changes, and therapist impressions based on the session. In contrast, the mental status exam (MSE) is an objective, structured evaluation of the client’s current cognitive, emotional, and behavioral presentation.
If a client’s diagnosis changes, what must also be updated in their documentation?
The treatment plan and any necessary justifications in the progress notes.
Name at least 2 key components that should be included when defending medical necessity in a progress note?
Client symptoms, functional impairment, risk factors, treatment plan alignment, client benefits, and clinician’s rationale for continued care.
When is it appropriate to release client records without client consent?
When required by court order, mandated reporting (abuse, safety concerns), or state/federal laws (e.g., public safety risk).