Documentation Standards
•ASSESSMENT
•The following areas will be included as appropriate as part of a comprehensive client record (continued):
I.Documentation will include past and present use of tobacco, alcohol, and caffeine, as well as illicit, prescribed and over the counter drugs.
J.A relevant mental status examination will be documented.
K.A five axes diagnosis from the most current DSM, or a diagnosis from the most current ICD, will be documented, consistent with the presenting problems, history, mental status evaluation and/or other assessment data.
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