9780471689317

The Clinical Documentation Sourcebook: The Complete Paperwork Resource for Your Mental Health Practice, 3rd Edition

by
  • ISBN13:

    9780471689317

  • ISBN10:

    0471689319

  • Edition: 3rd
  • Format: Paperback
  • Copyright: 2005-02-01
  • Publisher: Wiley

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Supplemental Materials

What is included with this book?

Summary

All the forms, handouts, and records mental health professionals need to meet documentation requirements 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. This updated and revised Third Edition provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing your practice. From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Third Edition offers sample forms for every stage of the treatment process. Greatly expanded from the second edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out, as well as fifty-two ready-to-copy blank forms. The included CD-ROM also provides these forms in Word format so you can easily customize them to suit your practice. With The Clinical Documentation Sourcebook, Third Edition, you'll spend less time on paperwork and more time with clients. Includes documentation for child, family, and couples counseling Updated for HIPAA compliance, as well as to reflect the latest JCAHO and CARF regulations New focus on clinical outcomes supports the latest innovations in evidence-based practice

Author Biography

DONALD E. WIGER, PHD, a psychologist, runs a large mental health clinic in St. Paul and is an adjunct professor at Argosy University School of Professional Psychology. He is the author of numerous books, including The Psychotherapy Documentation Primer, also from Wiley.

Table of Contents

CD Contents ix
Acknowledgments xi
Preface xiii
Introduction xv
Administrative and Intake Forms
1(1)
Introduction
1(6)
Screening Information
7(1)
Notice of Appointment
8(1)
Consent to Treatment and Recipient's Rights
9(1)
Recipient's Rights Notification
10(1)
Initial Client Information
11(2)
Example of completed form
12(1)
Financial Policy
13(1)
Payment Contract for Services
14(1)
Code of Ethics and Mission Statement
15(1)
Therapist's Ethics Statement
16(1)
Agreement Regarding Minors
17(2)
Preauthorization for Health Care
19
Forms Designed for HIPAA Compliance
1(1)
Introduction
1(7)
Privacy of Information Policies
8(2)
Request to Amend Health Records
10(1)
Request for Restricted Use/Disclosure of Records
11(1)
Request for Alternative Means of Confidential Information
12(1)
Release of Information Consent
13(1)
Record of Requests for Client Information
14(1)
Request for Listing of Disclosures of Client Records
15
Assessment Forms
1(1)
Introduction
2(7)
Initial Assessment---Adult
9(16)
Example of completed form
17(8)
Initial Assessment---Children and Adolescents (< 18)
25(16)
Example of completed form
33(8)
Personal History---Adult (18+)
41(8)
Example of completed form
49(8)
Personal History---Children and Adolescents (< 18)
57(16)
Example of completed form
65(8)
Couple's Information Form
73(5)
Emotional/Behavioral Assessment
78(8)
Example of completed form
82(4)
Emotional/Behavioral Update
86(2)
Example of completed form
87(1)
Diagnostic Assessment Report
88(12)
Example of completed form
94(6)
Diagnostic Assessment---Lower Functioning
100(8)
Example of completed form
104(4)
Biopsychosocial Report
108
Example of completed form
111
Psychological Evaluations
1(1)
Introduction
1(2)
Psychological Evaluation---Adult
3(26)
Example of completed form
16(13)
Psychological Evaluation---Children and Adolescents
29
Example of completed form
43
Treatment Planning Forms and Procedures
1(1)
Introduction
2(5)
Individual Treatment Plan
7(4)
Example of a Poor Treatment Plan
8(1)
Example of completed form---Adult
9(1)
Example of completed form---Children and Adolescents
10(1)
Short-Term Therapy Treatment Plan
11(2)
Example of completed form
12(1)
Treatment Review
13(4)
Example of completed form
15(2)
Treatment Update
17
Example of completed form
18
Progress Notes
1(1)
Introduction
2(6)
Progress Notes
8(4)
Example of Poor Progress Notes
9(1)
Example of completed form---Adult
10(1)
Example of competed form---Children and Adolescents
11(1)
Progress Notes---Outline
12(2)
Example of completed form
13(1)
Group Therapy Progress Notes
14(2)
Example of completed form
15(1)
Psychiatric Medication Management Progress Notes
16
Other Forms Used During the Course of Treatment
1(1)
Introduction
2(2)
Informed Consent for Medication
4(1)
Suicide Contract
5(1)
Cooperating in Child Rearing
6(5)
Couple's Analysis of Target Behaviors
11(4)
Example of completed form
13(2)
Third-Party Prior Authorization Request for Continued Services
15
Example of Poor Authorization Request
16(1)
Example of completed form
17
Chart Review and Outcomes Documentation
1(1)
Introduction
2(3)
Chart Review
5(2)
Utilization Review Committee Guide to Review Charts for Audit
7(3)
Utilization Review Committee---Chart Review Summary
10(1)
Medical Records Audit Chart
11(5)
Statement of Confidentiality for Those Auditing or Reviewing Client Charts
16(1)
Client Satisfaction Survey
17(1)
Clinical Outcomes Questionnaire
18
Termination and Aftercare
1(1)
Introduction
1(2)
Discharge Summary
3(4)
Example of completed form
5(2)
Termination Letter
7
Bibliography and Suggested Readings 1(1)
CD-ROM Information 1

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