Keeping Your Notes Clinical
Your session notes are legal documents. You must write objectively. Subjective writing includes opinions or feelings. Objective writing includes facts.
The Difference
Subjective: "Client was happy today." (How do you know?)
Objective: "Client smiled and laughed during breaks." (This is observable).
Subjective: "Client was manipulative."
Objective: "Client looked at RBT before dropping toy."
Why It Matters
Insurance companies fund services based on medical necessity, not feelings. Measurable data proves that therapy is effective. It protects you from accusations of bias.
Exam Tip
If a question asks for the best session note, choose the one that describes actions, not internal states. "He hit" is better than "He was aggressive." Focus on topography.