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.