Reviewing documentation before sessions

“Review clinical documentation before client sessions” (NBCC, 2027 task 5.6)

Reviewing a client's record before each session helps the counselor pick up where the last session ended, follow through on plans, and notice risk and progress. It is a simple habit that supports continuity and safety. The exam tests its purpose and what to review.

Key points

Review the last progress note, the current treatment plan goals, any homework or agreed actions, and recent outcome measures.
Check for risk information, safety plans and follow-up items that need attention.
Look for new information from other providers, collateral contacts or messages since the last session.
Note upcoming plan reviews, authorization limits or administrative requirements.
Reviewing helps the client feel remembered and supports a coherent, goal-directed session.
Before seeing a client for the first time, review intake and referral information, and, for transferred clients, prior records shared with consent.
Protect confidentiality while reviewing: use secure systems and avoid viewing records where others can see.

In practice

Before a session, a counselor reads her last note and sees that the client planned to talk with his boss about his schedule. She opens the session by asking how that conversation went, and the client is surprised and pleased she remembered.

Reviewing a chart before a session, a counselor notices a message from the client's physician about a new diagnosis of diabetes. She plans to check how the client is coping with the news.

Check yourself

Name three things to review before a client session.

The last progress note, current treatment goals and any agreed homework, along with risk information and outcome measures.

How does reviewing records support client safety?

It brings risk information, safety plans and follow-up items to the counselor's attention before the session.

Why does reviewing notes help the therapeutic relationship?

Clients feel remembered and the session builds on previous work.

NBCC's knowledge and skills for Domain 5

Knowledge of: Documentation practices and models; Release of information and confidentiality; Basic psychopharmacological information; Professional roles; Record retention and management.

Skill in: Completing case notes; Case conceptualization; Advocating for client.

A study guide written by ExamDragon from NBCC's published task; not NBCC material and not part of the exam.