NCTRC EXAM – DOCUMENTATION
QUESTIONS AND ANSWERS
what are the 3 Principles of Quality Client Documentation? - Correct Answers -
Consistency and Accuracy of Information
Conciseness in Client Documentation
Clarity in Client Documentation
Source Oriented Medical Records (SOMR): - Correct Answers -Narrative Format
Assessment - Correct Answers -conclusions based on data review
o Example: anxiety level is slowly decreasing & there appears to be an inability to
express feelings.
Plan - Correct Answers -plan believed to resolve the problem
o Continue plan as outlined in initial plans.
Intervention - Correct Answers -specific intervention implemented
evaluation - Correct Answers -Patient's response to interventions
revision - Correct Answers -changes made from the original treatment plan
what is an example of focus charting? - Correct Answers -DARP
Subjective data - Correct Answers -gathered from client
o Example: stated feelings.
Objective data: - Correct Answers -based on observation & other sources
o Example: engaged in activity for 40 minutes.
what does DARP stand for? - Correct Answers -data, action, response, plan
Purpose is to make trends in patient status more obvious, reduce the amount of time
spend in documentation, and make current information about the patients status readily
available. - Correct Answers -charting by exception - CBE
what does SMART stand for? - Correct Answers -Specific, Measurable, Achievable,
Realistic, Timely
