Mastering Accurate Patient Documentation
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Questions and Answers

Which of the following should be reflected in documentation?

  • Intervention(s) prescribed
  • Patient's objective symptoms
  • Behavioral issues triggering the psychotherapeutic interaction
  • Medical or behavioral health changes or challenges (correct)

    • What is the purpose of documentation in psychotherapy?

  • To record the patient's subjective symptoms
  • To substantiate the level of care billed
  • To track behavioral issues triggering the psychotherapeutic interaction
  • To document the intervention(s) prescribed (correct)

    • Which factor is NOT required to be reflected in documentation?

  • Patient's objective symptoms (correct)
  • Behavioral issues triggering the psychotherapeutic interaction
  • Patient's subjective symptoms
  • Intervention(s) prescribed

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