Documentation Standards
•ASSESSMENT
•The following areas will be included as appropriate as part of a comprehensive client record (continued):
D.Special status situations that present a risk to client or others will be prominently documented and updated as appropriate.
E.Documentation will include medications that have been prescribed by mental health plan physicians, dosages of each medication, dates of initial prescriptions and refills, and documentation of informed consent for medications.
F.Client self-report of allergies and adverse reactions to medications, or lack of known allergies/sensitivities will be clearly documented.