The Clinical Documentation Sourcebook: The Complete Paperwork Resource for Your Mental Health Practice, 4th Edition

by Donald E. Wiger

• ISBN13: 9780470575857
• ISBN10: 0470575859
• Format: eBook
• Copyright: 2010-01-01
• Publisher: Wiley

Summary

All the forms, handouts, and records mental health professionals need to meet documentation requirements fully revised and updatedThe 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 Microsoftreg; 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.

Table of Contents

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

Confidentiality 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

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

Progress Notes

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

CD-ROM Table of Contents

About the CD-ROM

Table of Contents provided by Publisher. All Rights Reserved.