condense: A concise treatment plan is necessary, outlining proposed interventions, goals, and follow-up strategies. This plan should directly relate to the diagnosed conditions to ensure an effective approach to care. Additionally, any current medications should be documented, including their dosages and frequencies. This information is key for ensuring safe pharmacological management and allows for assessing medication efficacy. Moreover, any assessment tools used during the evaluation should be cited. The inclusion of standardized questionnaires or scales supports the findings and may provide objective measures for tracking progress. A comprehensive risk assessment is also essential. This evaluation determines the patient's risk for self-harm or harm to others, and proper documentation is crucial for ensuring safety and guiding the treatment approach. Informed consent must be documented, indicating that the patient understands the proposed treatment, risks, and alternatives. This step ensures ethical practice and legal compliance. Finally, recording the duration of the session is important for billing processes. Accurate timesheets substantiate claims and demonstrate the intensity of care provided