Mental Health Documentation
Gain insights into the dos and don'ts of mental health documentation and improve documentation quality for high-quality client care.
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Commonly asked questions
Mental health documentation comprises all the detailed records associated with your mental health care. This commonly includes clinical notes, diagnoses, treatment plans, progress notes, medication prescriptions, monitoring, and informed consent and authorization forms.
The primary goals of documentation in the mental health field are to ensure continuity of care, facilitate treatment planning and monitoring, provide legal protection, improve care quality, and enhance communication.
To be effective and compliant, mental health documentation must follow the key requirements of accuracy, timeliness, completeness, clarity, and confidentiality.
