Documentation focus
Start with the reasoning frame, then use the article and sample item to see how it works.
- Record what the client said, what was observed, what was done, and how the client responded
- Avoid medical diagnosis, emotional judgment, and unrelated private details
- Documentation should be clear, objective, timely, and confidential
A record is not a personal reaction
The exam may distinguish subjective feedback, objective notes, assessment, and plan.
Good documentation stays objective and does not turn guesses into facts.
Privacy and accuracy matter together
Client records are sensitive and should not be shared casually.
When a question asks about records, choose clear, accurate, confidential, and process-based answers.
Sample item
Which note is most appropriate for a client record?
- Client was difficult and probably has a serious disease.
- Client reported right shoulder discomfort before the session.
- Client needs medical treatment from the therapist.
- Client's condition is not important to document.
Explanation：B is an objective client-reported note. The other choices diagnose, judge, or dismiss documentation.
Documentation terms
Know these terms first so the question stem and explanation are easier to judge.
- SOAP
- Subjective, Objective, Assessment, Plan.
- objective
- Observed or recordable facts.
- confidential
- Client records should not be shared casually.
Keep practicing this in the app
Articles explain the reasoning. The app is for daily drills, explanations, missed-question review, and final prep.
- Chapter practice
- Plain explanations
- Missed-question review