The Psychotherapy Documentation Primer

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 Fourth Edition of The Psychotherapy Documentation Primer continues to reflect HIPAA and accreditation agency requirements as well as offer an abundance of examples.

Fully updated to include diagnostic criteria of the DSM-5, The Psychotherapy Documentation Primer, 4th Edition is designed to teach documental skills for the course of psychotherapy from the initial interview to the discharge. The documentation principles discussed in the text satisfy the often-rigid requirements of third-party insurance companies, regulating agencies, mental health licensing boards, and federal HIPAA regulations. More importantly, it provides students and professionals with the empirical and succinct documentation techniques and skills that will allow them to provide clear evidence of the effects of mental health treatment while also reducing the amount of their time spent on paperwork.

Donald E. Wiger, Ph.D., is a practicing psychologist in St. Paul, MN, specializing in conducting psychological evaluations for a variety of purposes. He has taught graduate courses in psychological assessment for over 30 years. He has written several texts in areas of documentation, clinical forms, interviewing, outcomes, and crisis intervention. He conducts seminars, nationally, in areas such as documentation, interviewing, and private practice.

Preface

How This Book Came Into Being: A Lesson in Making a Really Bad Negative into a Really Good Positive

Chapter 1 Introduction

Chapter 2 The Art and Science of Psychological Assessment and Treatment

Chapter 3 Overview of Current Documentation Procedures and Third-Party Requirements

Chapter 4 Ethical Considerations in Documentation

Chapter 5 The Biopsychosocial Assessment

Chapter 6 The Clinical Interview:  Mental Status Exam

Chapter 7 The Clinical Interview: Validating a Diagnosis 

Chapter 8 Formulating a Treatment Plan

Chapter 9 Writing Progress Notes

Chapter 10 Documenting the Need for Additional Services

Chapter 11 Documenting Mental Health Treatment Outcomes for Individuals

Appendix A Putting it all Together: Documented Chart for Mental Health Services

Appendix B Overview of HIPAA Guidelines in Mental Health Settings

Appendix C Example of Results of a Recent Mental Health Boards Action Due to a Therapist’s Documentation Issues

Appendix D Documenting Suicidality

Glossary

Bibliography and Suggested Readings

Index

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