What Must Always Be Documented in the Patient Record and Is

question 62

Multiple Choice

What must always be documented in the patient record and is the major billing factor for reporting codes in the Psychiatric subsection?

• A)patient status
• B)complexity
• C)fee
• D)time

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Definitions:

Therapeutic Efficacy

Refers to the ability of a treatment or therapy to produce a beneficial effect on the condition or disease it is designed to treat.

Diagnosis

The process of learning more about the client for the purpose of understanding the client’s presenting issue and potentially identifying the presence of a mental disorder.

DSM

The Diagnostic and Statistical Manual of Mental Disorders, a comprehensive classification system for mental health diagnoses.

Edition

A particular form or version of a published work, often differentiated by alterations, updates, or corrections.