CBHT Patient Observation & Documentation

Question 1

Why is objective documentation important in behavioral health?

Accepted Answer

To provide clear, unbiased information

Answer

To record personal opinions

Answer

To entertain other staff

Answer

To diagnose patients

Question 2

What should a Behavioral Health Technician include in documentation?

Accepted Answer

Factual, time-stamped behavior descriptions

Answer

General feelings about the client

Answer

Speculations about past trauma

Answer

Private conversations with other staff

Question 3

What does it mean if a patient is described as 'oriented x3'?

Accepted Answer

The patient knows their name, location, and date

Answer

The patient is in a trance state

Answer

The patient has elevated blood pressure

Answer

The patient is hallucinating

Question 4

Which observation is appropriate to include in a behavioral health chart?

Accepted Answer

Client was pacing and yelling loudly

Answer

Client seemed angry

Answer

Client doesn’t like staff

Answer

Client is a difficult person

Question 5

When should documentation be completed?

Accepted Answer

As soon as possible after the event

Answer

At the end of the week

Answer

After leaving the facility

Answer

Before the next staff meeting

Question 6

What is the primary reason for documenting patient behaviors?

Accepted Answer

To support care planning and accountability

Answer

To gossip with staff

Answer

To fill in extra time

Answer

To avoid patient contact