ACBHCS QA 4.2013 - Alameda County Behavioral Health

General Principles of
Documentation cont.
• Rationale for ordering ancillary services should be
easily inferred
• Past and present diagnoses should be accessible
• Appropriate health risk factors should be identified
• Document the client's response to, changes in
treatment, and revision of diagnosis
• The CPT and ICD‐9‐CM codes reported should be
supported.