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A comprehensive overview of documentation practices in counseling, emphasizing its importance as a clinical tool, legal document, and means to ensure continuity of care. It outlines the roles of documentation in various aspects of counseling, including clinical supervision, quality assurance, and legal proceedings. The document also delves into specific requirements for record retention in illinois, highlighting the duration for treatment and medical records. Additionally, it explores the elements of screening documentation and the comprehensive biopsychosocial assessment, which forms the foundation of client records.
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Roles of documentation - ✔✔1. clinical tool
Documentation as accountability - ✔✔recording information that is used for billing purposes, financial audits or reviews to ensure compliance with various standards.