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28.4 Documentation Requirements
Those services not supported by required documentation in the client's record are subject to recoupment.
Each client for whom services are billed must have the following documentation included in their records, and the documentation must comply with the standards indicated (below) in the first listed item:
• All entries must be documented clearly, legible to individuals other than the author, dated (month/day/year), and signed by the performing provider.
•Notations of the beginning and ending session times.
•All pertinent information regarding the client's condition to substantiate the need for services, including but not limited to the following:
•Diagnosis (background, symptoms, impression).
•Behavioral observations during the session.
•Narrative description of the counseling session.
•Narrative description of the assessment, treatment plan, and recommendations.
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