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The Psychotherapy Documentation Primer

ISBN: 9780470903964 | 0470903961

Edition: 3rd
Format: Paperback
Publisher: John Wiley & Sons Inc
Pub. Date: 12/27/2011

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Summary Table of Contents Author Biography

Fully updated to reflect the latest practice and reporting requirements, The Psychotherapy Documentation Primer, Third Edition is the benchmark record-keeping reference for working mental health professionals. It demystifies the entire documentation process and includes everything a therapist needs to know to record client intake, treatment, and progress-fully incorporating the latest managed care, accrediting agency, and government regulations. Immensely practical, the book: Discusses the rationale for each step of the therapeutic process Prov... MOREides training as to correct terminology, assessment, diagnoses, and progress notes documentation required for third-party payers and accreditation agencies. Features instructional tools for classroom and internship use including end of chapter summaries, questions with answers, and a glossary In addition, this Third Edition includes four new chapters and new documented client charts: New chapter: The Art and Science of Psychological Assessment and Treatment New chapter: Ethical and Cultural Considerations New chapter: Integrating Non-conflicting and Conflicting Observations, Client Statements, the MSE, Previous Records, and Testing New chapter: Words of Wisdom: Being a Successful Mental Health Professional New: Four new documented client charts covering chemical dependency services, psychological/vocational services, neuropsychometric services, and developmental delays

Everything you need to know to record client intake, treatment, and progress-incorporating the latest managed care, accrediting agency, and government regulations Paperwork and record keeping are day-to-day realities in your mental health practice. Records must be kept for managed care reimbursement; for accreditation agencies; for protection in the event of lawsuits; to meet federal HIPAA regulations; and to help streamline patient care in larger group practices, inpatient facilities, and hospitals. The standard professionals and students have turned to for quick and easy, yet comprehensive, guidance to writing a wide range of mental health documents, the Third Edition of The Psychotherapy Documentation Primer continues to reflect HIPAA and accreditation agency requirements as well as offer an abundance of examples. The new edition features: Revised examples of a wider range of psychological concerns New chapters on documentation ethics and the art and science of psychological assessment and psychotherapy Study questions and answers at the end of each chapter Greatly expanded, The Psychotherapy Documentation Primer, Third Edition continues to be the benchmark record-keeping reference for working professionals, reflecting the latest in documentation and reporting requirements.

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Preface	p. vii
How This Book Came Into Being: A Lesson in Making a Really Bad Negative Into a Really Good Positive	p. ix
Introduction	p. 1
The Art and Science of Psychological Assessment and Treatment	p. 5
Overview of Current Documentation Procedures and Third-Party Requirements	p. 11
Ethical Considerations in Documentation	p. 35
The Biopsychosocial Assessment	p. 47
The Mental Status Exam	p. 81
Validating a Diagnosis	p. 95
Formulating a Treatment Plan	p. 117
Writing Progress Notes	p. 145
Documenting the Need for Additional Services	p. 175
Putting it All Together: Documented Chart for Mental Health Services	p. 181
Overview of Outcome Measures	p. 201
Overview of HIPAA Guidelines in Mental Health Settings	p. 207
Glossary	p. 211
References and Suggested Readings	p. 221
Index	p. 225
Table of Contents provided by Ingram. All Rights Reserved.

Donald E. Wiger, PHD, is a practicing psychologist in St. Paul, Minnesota, specializing in conducting psychological evaluations for a variety of purposes. He has taught graduate courses in psychological assessment for over twenty years and has written several texts in the areas of documentation, clinical forms, interviewing, outcomes, and crisis intervention. He conducts seminars nationally in areas such as documentation, interviewing, and private practice.

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