Diagnosis

Standard 12: Where there is a diagnosis or diagnoses, it/they should be recorded.

Criterion

12a    Where there is a diagnosis or diagnoses, the mental health care record shows:

  • the diagnosis or diagnoses
  • information on how the diagnosis or diagnoses was/were reached following established diagnostic criteria, where available
  • the formulation
  • confirmation that the diagnosis or diagnoses has/have been explained to the child or young person and their parents/carers
  • that the information is shared, where appropriate, with partner agencies
  • that information on the condition has been given, and
  • that where the child or young person and/or their parents/carers disagree with the diagnosis or diagnoses, there is a system to record this.

 

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