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.