Which of the following is NOT recommended when documenting notes?

• A. Describe symptoms, behaviors, and progress; reflect interventions; maintain confidentiality; use standardized formats; date/time.
• B. Avoid using nonjudgmental language and instead include personal judgments.
• C. Describe progress and responses to interventions.
• D. Date and time entries.

Answer: (B)

Keeping notes factual, observable, and nonjudgmental is essential. Documentation should clearly describe symptoms and behaviors, the client’s progress, and how interventions are working, while also noting date and time, and preserving confidentiality through standardized formats. The option that says to avoid nonjudgmental language and instead include personal judgments is not recommended because personal judgments introduce bias and subjectivity into the record. They can obscure what actually happened, reduce reliability for other professionals, and potentially harm the client’s treatment or rights. Use objective, observable descriptions such as what the client reports, what was observed during sessions, and concrete responses to interventions. The other practices—documenting symptoms and progress, noting responses to interventions, and dating entries—align with solid clinical documentation standards.