01
Choose one
1 point
A draft session note says, “Jordan was being defiant” after being instructed to put away the blocks. Which revision best uses objective documentation?
Free Practice Quiz Question List
6 Documentation and Reporting Online Quiz Questions
Use this free practice quiz with 20 questions to review 6 Documentation and Reporting, test your knowledge, and prepare for your next test or exam.
20 questions
02
Fill in the blank
1 point
Complete the statement: A useful session note is factual, specific, , and understandable to another authorized team member.
03
Choose one
1 point
A session ends earlier than planned. Which documentation approach is appropriate for the service and attendance records?
- A
Record the full planned service because that was the scheduled duration.
- B
Record the services actually provided, following the employer’s and payer’s requirements.
- C
Leave the service duration unchanged unless the client’s caregiver requests a correction.
- D
Estimate the duration from the session plan if the actual time is unclear.
04
True or false
1 point
If an RBT makes an error in a record, the correction should follow the organization’s approved method and leave the original entry and correction clear.
- A
True
- B
False
05
Written response
1 point
A session note and data sheet conflict about a recorded total. Which role should the RBT ask before resolving the discrepancy?
06
Choose all
1 point
Which situations should an RBT promptly report to the supervisor because they may affect safe or effective service? Select all that apply.
- A
A caregiver reports a change in the client’s medication.
- B
The RBT wants to revise a goal without consulting the supervisor.
- C
Attendance or participation changes in a way that may affect service.
- D
A new environmental barrier makes it difficult to follow the written plan as directed.
- E
The RBT prefers a different data-sheet layout.
07
Fill in the blank
1 point
When documenting an incident, record the facts without speculation or .
08
Choose one
1 point
An RBT realizes that client information was sent to the wrong recipient. What should the RBT do?
- A
Wait to see whether the unintended recipient opens the message.
- B
Delete any remaining copies and take no further action.
- C
Notify the supervisor or designated privacy contact immediately and follow reporting procedures.
- D
Send the information again to the intended recipient without reporting the first disclosure.
09
Choose all
1 point
Which practices help protect client information during routine work? Select all that apply.
- A
Keep paper records secure.
- B
Use required safeguards to protect devices and accounts.
- C
Discuss identifiable client details in a public space if names are omitted.
- D
Verify recipients before sending client information.
10
True or false
1 point
HIPAA automatically applies to every organization and every client record, regardless of the organization’s status.
- A
True
- B
False
11
Written response
1 point
When HIPAA applies, what is the name of the general rule that limits certain uses and disclosures of protected health information to what is needed for the purpose?
12
True or false
1 point
After notifying a supervisor about a reportable concern, an RBT should still follow any applicable mandated-reporting requirements rather than assuming the supervisor notification replaces them.
- A
True
- B
False
13
Choose one
1 point
An RBT is unsure whether a procedure in the written behavior plan should be changed for a client. What is the appropriate response?
- A
Make a small change to the procedure and document it afterward.
- B
Follow the written plan and refer the question to the supervisor.
- C
Change the goal to fit the situation.
- D
Try a different procedure and decide which works better.
14
Open ended
1 point
A client is injured during a service session. Describe the RBT’s immediate priorities and follow-up responsibilities, including what to document and how to handle any applicable mandated-reporting requirement.
15
Choose one
1 point
Which session-note statement is the most objective and specific?
- A
Jordan was being defiant and did not want to clean up.
- B
After the instruction to put away the blocks, Jordan said “no,” pushed the bin away, and did not begin cleanup during the next 30 seconds.
- C
Jordan became upset because cleanup was difficult.
- D
Jordan refused to cooperate for the rest of the session.
16
Choose one
1 point
A session note and a data sheet show different service times. What should the RBT do?
- A
Choose whichever value makes the records consistent.
- B
Leave out the conflicting information and submit the records.
- C
Promptly ask the supervisor how to resolve the discrepancy.
- D
Change the data sheet to match the billing record without notifying anyone.
17
Choose one
1 point
An appointment was scheduled for a full session, but the service ended early. What principle should guide the RBT’s service documentation?
- A
Document only the services actually provided.
- B
Document the full planned session if the client was scheduled to attend.
- C
Record missed services as completed if they were part of the treatment plan.
- D
Use the usual session length when the actual duration is uncertain.
18
Choose one
1 point
A caregiver tells the RBT that the client’s medication changed. What is the most appropriate response?
- A
Decide whether the change is clinically important and adjust the behavior plan.
- B
Wait until the next scheduled supervision meeting before mentioning the change.
- C
Ask the caregiver to change the client’s medication before the next session.
- D
Promptly tell the supervisor what was reported or observed and what action the RBT took.
19
Written response
1 point
According to the material, which two categories does HIPAA apply to? Enter both in a short phrase.
20
Written response
1 point
When correcting a documentation error, what two things must remain clear in the record?