Guidelines for Effective Documentation

Question 1

Documentation

Answer 1

A written form of communication with the purpose of ensuring that events that take place are properly recorded

Question 2

Variables that affect clients

Answer 2

Noticeable changes or issues with clients that affect treatment and need to be reported

Question 3

Frequency

Answer 3

An indication of how many times a behavior or event occurs

Question 4

Duration

Answer 4

An indication of how long a behavior lasts

Question 5

Interval recording

Answer 5

Used to record whether a behavior occurs during a particular interval

Question 6

A-B-C recording

Answer 6

Writing down an antecedent (or what happened before a behavior occurred), the behavior, and the consequence (or what happened after the behavior occurred)

Question 7

Anecdotal recording

Answer 7

Writing down everything that happened

Question 8

Session notes

Answer 8

Documentation of what happened during the session

Question 9

Incident reports

Answer 9

Documentation of unusual events that occur during service provision, which are called incidents

Question 10

PHI

Answer 10

protected health information, which is any health information that can be used to identify a patient or client

Question 11

e-PHI

Answer 11

Protected health information in an electronic form

Question 12

Minimum necessary rule

Answer 12

Information about clients that can be shared only to the extent that it accomplishes the goal

Question 13

Observable and measurable language

Answer 13

Descriptions of what can be seen, heard, felt, or counted