Published September 5, 2026

Documentation and SOAP Notes on the NCMHCE: What Goes In, What Stays Out, and the Rules

By David Zimmerman · 8 min read · Clinical content

Documentation items sit in Domain 5 and spill into Domains 2A and 6^[1]. They ask four things: what goes in a note, where it goes, what stays out, and what the rules are for access, correction, and retention. The standards are the ACA Code’s records section (B.6)^[2], HIPAA’s definitions of the record and of psychotherapy notes^[3], and the SOAP structure most agencies use. This post gives you all four and seven items to practice sorting.

SOAP, and its cousins

Section	Contains	Does not contain
S — Subjective	What the client reports: symptoms, events, feelings, goals, in the client's own words where useful	Your observations or opinions
O — Objective	What you observe and measure: affect, appearance, behavior, MSE findings, instrument scores administered, attendance	Client self-report; interpretations
A — Assessment	Your clinical formulation: what S and O mean, diagnosis status, progress toward each goal, risk assessment	New data; the plan
P — Plan	Interventions used and planned, homework, referrals, coordination, next appointment, safety plan updates	Formulation

DAP (Data, Assessment, Plan) folds S and O into Data; BIRP (Behavior, Intervention, Response, Plan) is common in community settings. The exam tests the logic, not the acronym: report vs. observation vs. interpretation vs. action.

What stays out

Speculation and characterization. “Manipulative,” “drama,” opinions about a third party’s motives. Record behavior and statements.
Other agencies’ plans. A CPS investigative timeline belongs to CPS; your note records that you reported, when, and to whom. See Domain 5.
Diagnostic overreach. Side effects are not treatment resistance; a screening score is not a diagnosis.
Details beyond the minimum necessary in anything that leaves your file: summaries to schools, employers, insurers^[3].
Third-party information the client has not authorized you to share, in records you release.

The rules

Rule	What the exam keys
Timeliness	Notes are written promptly after the session; a late note is dated when written and identifies the session date.
Corrections	Dated, signed addendum; the original stays intact and legible. Never delete or obscure.
Client access	Competent clients may access their records (ACA B.6.e; HIPAA right of access); limit only for documented harm, and only the necessary part.
Psychotherapy notes	HIPAA: private process notes kept separate from the record get extra protection; progress notes do not. Mixing them into the chart removes the protection.
Releases	Written, specific, time-limited; the client may revoke. Minimum necessary applies to what is sent.
Retention	Follow state law and agency policy; ACA requires records be maintained and disposed of per law and in a way that protects confidentiality (B.6.g–h).
Transfer or closure	Plan for records when you leave, close, or die (B.6.i); clients know how to obtain them.
Telehealth and technology	Same documentation standard; note the modality, the client's location, and consent to the platform (ACA H).

The test a note must pass

Could another clinician pick up this client from your notes alone, and would you be comfortable reading them aloud in front of the client and a judge? Objective language, client quotes, a formulation, and a plan pass both.

Documentation decisions are in the free drills

The medication side-effect drill and the mandated-report documentation drill both turn on what goes in the note. 18 free drills, no card.

Start free

Sort the sentence

Interactive

Documentation on the NCMHCE

1 of 7

"Client reports sleeping four hours a night and states, 'I can't turn my brain off.'" In a SOAP note this belongs under:

Domain 5 practice questions (playable).
Ethics scenarios for subpoenas and releases.
Telehealth and AI ethics for AI note-writing tools and BAAs.

Sources

Frequently asked questions

What is the difference between psychotherapy notes and progress notes under HIPAA?

Psychotherapy notes are a clinician's private process notes kept separate from the medical record and given extra protection; they exclude diagnosis, treatment plan, medication, session times, and progress. Progress notes document those and are part of the record. The protection applies only when the notes are actually kept separate.

How do I correct an error in a clinical note?

With a dated, signed addendum that identifies and corrects the error while leaving the original intact and legible. Never delete, overwrite, or obscure the original.

Ready to practice?

Start drilling NCMHCE-style questions for free — no credit card required.

Start Free Practice →