The Clinical Documentation Sourcebook The

All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated

The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice.

The Fourth Edition offers:

-Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families

-Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations

-A new chapter covering the most current format on screening information for referral sources

-Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment

-A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices

From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out.

DONALD E. WIGER, PHD, a psychologist, is director of a mental health clinic in St. Paul, Minnesota. He has taught graduate psychology students for twenty years and provided training seminars to thousands of mental health professionals throughout the United States. He is the author of numerous books, including The Psychotherapy Documentation Primer, Second Edition, also from Wiley.

Preface to the Fourth Edition
Introduction
Administration and Intake Forms
Introduction
Screening Information
Notice of Appointment
Consent to Treatment and Recipient's Rights
Recipient's Rights Notification
Financial Policy
Payment Contract for Services
Code of Ethics and Mission Statement
Therapist's Ethics Statement
Agreement Regarding Minors
Preauthorization for Health Care
Confi dentiality Agreement
Forms Designed for HIPAA Compliance
Introduction
Privacy of Information Policies
Request to Amend Health Records
Request for Restricted Use/Disclosure of Records
Request for Alternative Means of Confidential Information
Release of Information Consent
Record of Requests for Client Information
Request for Listing of Disclosures of Client Records
Screening Information
Mental Health Screening Form
Substance Abuse Screening Form
Adaptive Functioning Screening Form
Learning Disability Screening Form
ADHD Screening Form
Assessment Forms
Introduction
Initial Assessment-Adult
Example of Completed Form
Initial Assessment-Children and Adolescents (_18)
Example of Completed Form
Personal History-Adult (18_)
Example of Completed Form
Personal History-Children and Adolescents (_18)
Example of Completed Form
Couple's Information Form
Emotional/Behavioral Assessment
Example of Completed Form
Emotional/Behavioral Update
Example of Completed Form
Diagnostic Assessment Report
Example of Completed Form
Diagnostic Assessment-Lower Functioning
Example of Completed Form
Biopsychosocial Report
Example of Completed Form
Psychological Evaluations
Introduction
Psychological Evaluation-Adult
Example of Completed Form
Psychological Evaluation-Children and Adolescents
Example of Completed Form
Psychological/Vocational Assessment
Neuropsychometric Consultation
Treatment Planning Forms and Procedures
Introduction
Individual Treatment Plan
Example of a Poor Treatment Plan
Example of Completed Form-Adult
Example of Completed Form-Children and Adolescents
Short-Term Therapy Treatment Plan
Example of Completed Form
Treatment Review
Example of Completed form
Treatment Update
Example of Completed Form
Progress Notes
Introduction

Example of Poor Progress Notes
Example of Completed Form-Adult
Example of Competed Form-Children and Adolescents
Progress Notes-Outline
Example of Completed Form
Group Therapy Progress Notes
Example of Completed Form
Psychiatric Medication Management Progress Notes
Other Forms Used during the Course of Treatment
Introduction
Referral for Mental Health Services
Informed Consent for Medication
Suicide Contract
Cooperating in Child Rearing
Couple's Analysis of Target Behaviors
Example of Completed Form
Third-Party Prior Authorization Request for Continued Services
Example of Poor Authorization Request
Example of Completed Form
Chart Review and Outcomes Documentation
Introduction
Chart Review
Utilization Review Committee Guide to Review Charts for Audit
Utilization Review Committee-Chart Review Summary
Medical Records Audit Chart
Statement of Confidentiality for Those Auditing or Reviewing Client Charts
Outcome Survey for Adults
Outcome Survey for Children
Outcome Survey for Families and Relationship
Termination and Aftercare
Introduction
Discharge Summary
Example of Completed Form
Termination Letter
Bibliography and Suggested Readings
Table of Contents provided by Publisher. All Rights Reserved.

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The Clinical Documentation Sourcebook The Complete Paperwork Resource for Your Mental Health Practice

Summary

Author Biography

Table of Contents

Supplemental Materials