Documentation
Standards
ASSESSMENT
The following areas will be included as appropriate as
part of a comprehensive client
record (continued):
G.A mental health
history will be documented, including: previous treatment dates, providers, therapeutic
interventions and
responses, sources of clinical data, relevant family information and relevant results of relevant lab tests
and consultation
reports.
H.For children and
adolescents, pre-natal and perinatal events and complete developmental history will be
documented.