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The Paper Office, Third Edition Forms, Guidelines, and Resources to Make Your Practice Work Ethically, Legally, and Profitably

by: Zuckerman, Edward L.

The Paper Office, Third Edition Forms, Guidelines, and Resources to Make Your Practice Work Ethically, Legally, and Profitably

by: Zuckerman, Edward L.

ISBN 13:
9781572307698
ISBN 10:
1572307692
Edition: 3rd
Format: Paperback
Copyright: 01/28/2003
Publisher: The Guilford Press
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Summary

This popular manual and CD-ROM provide the clinical, financial, and legal record-keeping tools that every psychotherapy practice needs. It is ideal both for new practitioners who want to hit the ground running, and seasoned pros who want to overhaul their paperwork and risk-reduction procedures. Included are methods for documenting informed consent, treatment planning, and progress; advice on fee structures, competitive pricing, and billing; tips on joining managed care panels and communicating with MCO reviewers; and much more. New or expanded coverage is provided on managed care, clinical supervision, ethical marketing practices, malpractice insurance, and online resources. Updated to include 2002 changes in the American Psychological Association's Ethics Code, this new edition features more than 60 ready-to-use forms, checklists, and handouts, which may be duplicated directly from the book or from the accompanying CD-ROM.

List of Figures, Forms, and Handouts

xix

Introduction

(1)

Ways This Book Can Help You

(1)

What This Book Contains

(1)

Unique Features

(1)

How to Use This Book in Your Practice

(1)

Quick Start: Recommended Core Materials

(1)

Availability of Materials on CD-ROM

(1)

A Cautionary Note and Disclaimer

(1)

About Reproducing Materials in This Book

(1)

Your Forms and Other Contributions: A Nice Offer

(1)

Future Developments

(2)

Basic Paperwork and Communication Tools

(24)

Basic Paperwork Tools: An Overview

(1)

Presenting Yourself on Paper

(6)

Ethical Aspects of Self-Presentation

(1)

Guidelines for Clear and Accurate Self-Presentations

(1)

The Name of Your Practice

(1)

Your Stationery and Cards

(3)

Your Resume and Curriculum Vitae

(1)

Your Appointment Book

(2)

Figure 1. Sample curriculum vitae, partially filled in

(1)

What an Appointment Book Should Include

(1)

A List of Current Clients

(1)

Basics of Record Keeping

(7)

Why Keep Records?

(1)

What Should Be in the Records?

(1)

The Physical Structure for Organizing Your Case Records

(1)

Form 1. Checklist for client records

(3)

Record Security

(1)

Retention of Records

(7)

How Long Should Records Be Kept?

(1)

Suggestions on Retaining Records

(1)

Disposal of Your Records

(1)

Preserving Your Records When You Close Your Practice, Retire, or Die

(5)

Financial Tools and Procedures

(39)

Setting Financial Policies for Your Practice

(8)

About Fees

(1)

Ethical Guidelines on Fees

(1)

Setting Your Fee

(1)

Other Fee Arrangements

(3)

Discussing Fees

(1)

Tips on Collecting Fees

(1)

The Income Record

(2)

Figure 2. Sample monthly income record

(1)

The Expense Record I: Your Checkbook

(1)

Choosing a Checking Account

(1)

Guidelines for a Business Checkbook

(1)

Choosing a Credit Card

(1)

The Expense Record II: Monthly/Quarterly Expense Summary

(2)

Form 2. Monthly/quarterly expense summary

(1)

Methods of Billing

(4)

Credit Cards

(1)

Statements

(1)

SuperΨbills

(1)

Computerized Billing Programs

(1)

Billing Services

(1)

A Weekly Summary for Billing

(1)

A Record of Services Provided

(1)

Form 3. Record of services provided

(1)

Collecting Overdue Fees from Clients

(2)

Calling the Client

(1)

Sending a Note on the Bill

(1)

Sending Collection Letters

(1)

Other Methods

(1)

Billing Third Parties---and Getting Reimbursed

(7)

Advice on Procedures for Clients with Health Insurance

(1)

What You Need to Know for Insurance Processing

(2)

Billing for Medicare Patients

(1)

Checklist for Avoiding Illegal and Unethical Billing Procedures

(2)

Late Payments from Insurers

(1)

Authorization of Benefits

(1)

Marketing Your Practice Ethically

(13)

Practice Announcement Letters

(2)

A Referral-for-Psychotherapy Questionnaire

(1)

A Referral Form for Group Therapy

(1)

``Thanks for the Referral'' Notes

(1)

Form 4. Referral-for-psychotherapy questionnaire

(2)

Form 5. Referral form for group therapy

(3)

Sending Progress Notes to the Referrer or Cotreater

(1)

Where Do Your Referrals Come From?

(2)

Collecting Feedback on Your Psychological Reports

(1)

Reducing Malpractice Risk by Operating Ethically

(100)

Ethics and Malpractice

(4)

Why Are Ethical and Legal Issues So Complicated

(1)

The Major Malpractice Risks for Clinicians

(2)

Four Steps toward Ethical Self-Protection

(1)

Legal Aspects of Malpractice

(4)

When Do Patients Sue?

(1)

What Is Malpractice?

(1)

The Good News (for Us): The Real Risks Are Small

(1)

The Bad News (for Us): Malpractice Accusations Hurt

(1)

What to Do If You Are Complained Against: A Checklist

(2)

Professional Liability (``Malpractice'') Insurance

(14)

Introduction

(1)

Occurrence-Based versus Claims-Made Policies

(1)

Figure 3. An illustration of your coverage in claims-made and occurrence-based policies over time

(2)

Points of Comparison and Advantage

(1)

Guidelines and Issues to Consider When Purchasing Liability Insurance

(5)

Checklists for Comparing Professional Liability Insurance Policies

(4)

Other Kinds of Insurance You Might Need

(1)

Ways to Reduce Your Risk of Malpractice

(9)

Twenty-Two Steps for Risk Reduction

(6)

Other Risk Areas for Malpractice

100

(1)

Risks in Repressed-Memory Therapy

101

(2)

Evaluating the Ethicality of Proposed Treatments

103

(2)

Avoiding Malpractice in Psychological Testing

105

(4)

Require the Client to Give Consent

105

(1)

Know the Rules

106

(1)

Stay within Your Areas of Competence

106

(1)

Administer Tests the Way They Were Designed

107

(1)

Interpret and Report Your Findings Carefully

107

(1)

Be Alert for Biasing Factors

107

(1)

Be Aware of Forensic Issues

108

(1)

Be Thorough

109

(1)

Boundary Issues

109

(1)

Dual (or Multiple) Relationships

109

(5)

What Are Dual Relationships?

109

(1)

Why Avoid Dual Relationships?

109

(1)

Figure 4. Are you in trouble with a client?

110

(2)

Types of Dual Relationships

112

(1)

When Dual Relationships Are Not Avoidable: Weighing Their Effect

113

(1)

Preventing Trouble

114

(1)

Sexual Intimacies in Therapy

114

(15)

Handout 1. Patient handout on limits of the therapy relationship

115

(1)

What Is Meant by ``Sexual Intimacies''?

116

(1)

With Whom Are Sexual Intimacies Prohibited?

116

(1)

Who Is Prohibited from Engaging in Intimacies?

117

(1)

The Damage to the Client and to Therapy

117

(1)

Negative Consequences to the Clinician

118

(1)

Not Me! I Would Never!

119

(1)

Is Sexual Intimacy with a Client Ever Acceptable?

120

(2)

A Checklist of Preventive Measures

122

(1)

What to Do If a Client Asks You for Sex

122

(1)

Consciousness Raising

123

(1)

What to Do If You Are Attracted to a Client

124

(1)

Reporting Another Therapist

125

(1)

Client-Therapist Intimacy: Appropriate and Inappropriate Conduct

125

(1)

Handout 2. Patient handout on client--therapist contact

126

(3)

The Duty to Protect (and Warn)

129

(4)

The Legal Basis

130

(1)

When Do You Have a ``Duty to Warn''?

130

(1)

What to Do When You Decide to ``Warn''

131

(1)

Suicide

132

(1)

Family Violence and Abuse

132

(1)

Assessing a Client's Dangerousness to Self and Others

133

(10)

Prepare Ahead of Time

133

(1)

Gather Information to Assess Risk

133

(1)

Evaluate the Risk Factors Present

134

(3)

Form 6. Checklist of suicide risk factors

137

(3)

Analyze the Information Gathered

140

(1)

Document the Situation and Your Actions

141

(1)

Manage the Risk

141

(2)

Do Damage Control

143

(1)

Limit Your Personal Vulnerability to Violence

143

(1)

Ethical and Legal Issues in Working with Managed Care Organizations

143

(20)

Conflicts and Concerns

144

(1)

Joining an MCO Panel

144

(1)

Complexities in Your Contract with the MCO

145

(1)

Beginning to See MCO Clients

146

(1)

Initial Discussions with the Client about MCO-Related Ethical Issues

147

(2)

Verification of Coverage

149

(1)

Form 7. Behavioral health insurance benefits questionnaire

150

(3)

Dealing with MCO Reviewers

153

(1)

Continuity of Care Concerns

154

(1)

Educating Clients about Managed Care

155

(1)

Handout 3. Patient handout for education about/informed consent to managed care

156

(2)

The Concept of ``Medically Necessary'' Care

158

(1)

Coping with Administrative Burden, Fees, and Payments

158

(1)

Form 8. Medical-necessity-for-psychotherapy checklist

159

(1)

What Can a Clinician Do?

160

(3)

Legal and Ethical Aspects of Supervising and Being Supervised

163

(9)

Risks and Responses

163

(2)

A Formal Agreement

165

(1)

A Record of Supervision Meetings

165

(1)

Form 9. Agreement for professional supervision

166

(4)

Consulting

170

(1)

Resources for Supervision and Consultation

171

(1)

Getting Informed Consent

172

(73)

The What and Why of Getting Informed Consent

172

(8)

What Informed Consent Requires

172

(5)

The Three Steps to Obtaining Informed Consent

177

(1)

Do Written Consent Forms Have a Negative Effect on Clients or Treatment?

178

(1)

The Five Paths to Informed Consent

179

(1)

The First Path to Informed Consent: The Client Information Brochure

180

(26)

Kinds of Brochures

180

(1)

How to Use the Model Client Information Brochure

181

(1)

The Model Client Information Brochure

182

(24)

The Second Path to Informed Consent: The Question List as a Guide to Discussion

206

(5)

The Third Path to Informed Consent: List of Clients' Rights

211

(3)

Handout 4. Question list for therapist-client discussion (client's version)

212

(2)

About Handouts 5, 6, and 7

214

(1)

The Fourth Path to Informed Consent: Psychotherapy Contracts

214

(18)

The Nature of Contracts

214

(1)

Handout 5. First clients' rights form

215

(1)

Handout 6. Second clients' rights form

216

(1)

Handout 7. Third clients' rights form

217

(1)

Checklists for a Psychotherapy Contract: Elements and Options

218

(3)

A Contract for Individual Therapy with an Adult

221

(1)

Form 10. Contract for Individual adult therapy

222

(1)

About Contracts for Couples and Families

223

(1)

Contracts for Therapy with Minors

224

(2)

Form 11. Contract with parent/guardian for psychotherapy with a minor

226

(1)

Form 12. Contract for psychotherapy with an older child or adolescent

227

(1)

A Contract for Group Therapy

228

(1)

Form 13. Contract for group therapy

229

(3)

The Fifth Path to Informed Consent: Consent to Treatment and Other Services

232

(13)

Generic Consent to an Adult's Treatment

232

(1)

Generic Consent to a Minor Child's Treatment

232

(1)

Form 14. Form for generic consent to treatment of an adult

233

(1)

Form 15. Form for generic consent to treatment of a child

234

(1)

Consent to Counseling for a Child of Divorce

235

(1)

Authorization to Record Sessions and Use Case Materials

235

(1)

Form 16. Agreement for parents regarding limitations and goal of psychotherapy with a child of divorce

236

(2)

Form 17. Release/permission form for recording sessions and using case materials in research, teaching, and professional publishing

238

(3)

Consent to Psychological Testing

241

(1)

Consent to Being Evaluated for a Third Party

242

(1)

Form 18. Consent form and contract for psychological testing and evaluation

243

(1)

Form 19. Form for consent to being evaluated for a third party

244

(1)

Intake and Assessment Forms and Procedures

245

(66)

Creating the Client's Chart

245

(2)

The Chronology of Record Keeping

245

(1)

The Contents of the Record

246

(1)

Phase I: The Initial Telephone Contact

247

(3)

Reasons for Refusing a Caller as a Client

248

(1)

Getting the Essential Data

248

(2)

Phase 2: The Preappointment Package and Other Types of Preappointment Contact

250

(7)

Form 20. First-contact record

251

(1)

Ways to Respond before the Initial Appointment

252

(1)

Form 21. Appointment card or slip

253

(1)

Form 22. Letter of appointment confirmation

254

(1)

Ways of Dealing with No-Shows and Early Dropouts

255

(2)

Phase 3: The New Client's Arrival for a First Meeting

257

(29)

Ways of Collecting Further Client Information

257

(1)

Obtaining Client Demographic Information

258

(1)

Form 23. Client demographic information form

259

(3)

Obtaining Client Clinical Information

262

(1)

Form 24. Client clinical information form

263

(4)

Obtaining Client Medical Information

267

(1)

Form 25. Brief health information form

268

(4)

Assessing Chemical Use

272

(1)

Form 26. Chemical use survey

273

(2)

Obtaining Financial Information

275

(1)

Form 27. Financial information form

276

(3)

Assuring Financial Responsibility

279

(1)

Problem Checklists

279

(1)

Form 28. Agreement to pay for professional services

280

(2)

Form 29. Adult checklist of concerns

282

(2)

Form 30. Child checklist of characteristics

284

(2)

Obtaining Developmental Information

286

(1)

Phase 4: First Meeting with a New Client

286

(14)

Form 31. Child developmental history record

287

(3)

Preparing the Client for the Intake Interview

290

(1)

Using the Intake Interview Questions and Guide

291

(1)

Collecting Information from Young Adults

291

(1)

Special Considerations for Interviewing a Child

291

(1)

Form 32. Intake interview questions and guide

292

(2)

Form 33. Information form for young adults

294

(3)

The Evaluation of Mental Status

297

(1)

Form 34. Mental status evaluation and report

298

(2)

Phase 5: Summarizing the Intake Information

300

(11)

Summarizing Chemical Use and Suicide Risk Data

300

(1)

Formulating the Whole Case

300

(2)

Form 35. Chemical user's case formulation

302

(2)

Form 36. Suicide risk assessment summary and recommendations

304

(2)

Form 37. Intake summary and case formulation

306

(5)

Planning and Then Documenting Treatment

311

(52)

Treatment Planning

311

(15)

Issues

311

(1)

Guidelines for Treatment Planning

312

(1)

Systems and Formats of Treatment Planning

313

(1)

Other Points in Planning Treatment

314

(2)

Formulating Treatment Plans for Managed Care Organizations

316

(2)

Form 38. Individualized treatment plan for managed care organizations

318

(7)

About Managed Care Organizations' Own Checkoff Forms

325

(1)

Documenting Treatment's Progress

326

(21)

Note Taking: Guidelines and Suggestions

326

(10)

The Problem-Oriented Record

336

(2)

Form 39. Problem list for a problem-oriented record (POR)

338

(2)

Form 40. POR progress note form

340

(1)

Figure 5. Completed sample of a POR progress note form

341

(1)

Two Structured Progress Note Forms

342

(1)

Form 41. Structured progress note form

343

(2)

Client-Generated Records

345

(1)

Form 42. Structured progress note form for group therapy

346

(1)

Evaluating Each Therapy Session

347

(1)

Case Termination

347

(8)

Reasons for Terminating or Transferring a Patient

347

(1)

Form 43. Session evaluation questionnaire for clients

348

(3)

How to Terminate Treatment in Different Situations

351

(4)

The Case Closing Summary

355

(2)

Outline for Dictation

356

(1)

A Termination Summary Form

357

(1)

Assessing Client Satisfaction and Outcomes

357

(6)

Client Satisfaction Measures

357

(1)

Form 44. Termination summary form

358

(1)

Outcome Assessment Questionnaires

359

(1)

Cover Letters for These Questionnaires

359

(2)

Form 45. Client satisfaction follow-up questionnaire

361

(1)

Form 46. Client outcome follow-up questionnaire

362

(1)

Confidentiality and Releasing Records

363

(58)

Understanding Confidentiality

363

(13)

Basic Definitions

363

(2)

Exceptions to Confidentiality

365

(3)

Other Points about Confidentiality and Its Limitations

368

(2)

Confidentiality and Children

370

(1)

Confidentiality and HIV-Positive Clients

370

(1)

A Handout on the Limits of Confidentiality

371

(1)

Handout 8. Patient handout on the limits of confidentiality

372

(4)

Maintaining Confidentiality

376

(6)

Guidelines for Maintaining Confidentiality

376

(3)

A Checklist for Staff Training in Confidentiality

379

(1)

Creating Confidential Records

380

(1)

A Quick Test

381

(1)

Releasing Clients' Records

382

(13)

A Pretest

382

(1)

Ethical Considerations in Releasing Records

383

(1)

Legal Requirements for a Release of Records

384

(1)

Eight Variations on the Theme of ``Please Send Your Records''

385

(8)

Guidelines and Considerations in Sending Records

393

(1)

Comments on the Pretest

394

(1)

Forms for Requesting and Releasing Information

395

(4)

A Briefer Request/Release Form

395

(1)

A More Comprehensive Request/Release Form

395

(1)

Form 47. Briefer form for requesting/releasing confidential records and information

396

(1)

Form 48. Requesting or releasing confidential records and information

397

(2)

More Specific Forms for Releasing Information

399

(7)

A Release-of-Records Cover Letter

399

(1)

Releasing Psychological Test Results

400

(1)

Form 49. A release-of-records form letter

401

(2)

Releasing Information to an Attorney

403

(1)

Form 50. Request/authorization for release of evaluation information

404

(1)

Form 51. Authorization to release confidential information to an attorney

405

(1)

Releasing Records to an Insurance Company or Other Third-Party Payer

406

(1)

Releasing Information to the Patient's Family

406

(1)

Confidentiality When Faxing Records or Sending E-Mail

406

(5)

Form 52. Authorization to release confidential information to a health insurer or other third-party payer

407

(2)

Form 53. Authorization to release confidential information to family members

409

(2)

Confidentiality Notifications

411

(2)

Overview of HIPAA

413

(8)

Health Information and Its Uses

413

(1)

HIPAA and Privacy

414

(1)

Becoming ``HIPAA Compliant''

415

(1)

Notice of Privacy Practices

415

(1)

Documenting Consent

416

(1)

The Right to Object or Agree to Uses and Disclosures

417

(1)

The Right to Limit Disclosure of One's PHI

418

(1)

An Authorization to Send or Receive Records

418

(1)

Keeping an Accounting of Disclosures You Made

419

(1)

When Consent, Authorization, or Opportunity to Object Are Not Required

419

(2)

APPENDICES: RESOURCES

421

(10)

Books on Practice Development and Marketing

421

(1)

Readings in the Law, Ethics, and Malpractice

422

(1)

Professional Liability Insurance Resources

423

(1)

Practice Guidelines from Professional Organizations

424

(2)

Dealing with Managed Care Organizations

426

(2)

Resources for Supervision and Consultation

428

(3)

REFERENCES

431

(16)

INDEX

447

(12)

Feedback Form

457

(2)

Instructions for Installing The Paper Office's Forms onto Your Computer

459

Amazon no longer offers textbook rentals. We do!

The Paper Office, Third Edition Forms, Guidelines, and Resources to Make Your Practice Work Ethically, Legally, and Profitably

The Paper Office, Third Edition Forms, Guidelines, and Resources to Make Your Practice Work Ethically, Legally, and Profitably

9781572307698

1572307692

Summary

Author Biography

Table of Contents

Supplemental Materials

Write a Review

Amazon no longer offers textbook rentals. We do!

The Paper Office, Third Edition Forms, Guidelines, and Resources to Make Your Practice Work Ethically, Legally, and Profitably

The Paper Office, Third Edition Forms, Guidelines, and Resources to Make Your Practice Work Ethically, Legally, and Profitably

9781572307698

1572307692

Summary

Author Biography

Table of Contents

Supplemental Materials

Write a Review

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