Documenting Psychotherapy Essentials for Mental Health Practitioners

by Mary E. Moline; George T. Williams; Kenneth M. Austin

• ISBN13: 9780803946910
• ISBN10: 0803946910
• Format: Hardcover
• Copyright: 1997-09-09
• Publisher: Sage Publications

Summary

This concise volume examines exactly what is involved in keeping adequate clinical records of individual, family, couple and group psychotherapy. The authors discuss: limits of confidentiality; retention and disposing of records; documentation of safety issues; client access to records; treatment of minors; and training and supervision issues. Throughout the book, legal cases, vignettes and professional commentary help readers to consider legal and ethical issues.

Table of Contents

Preface	viii	(2)
Acknowledgments	x
PART I The Importance of Record Keeping in Psychotherapy	1	(28)
1. Protecting the Client and the Therapist	3	(16)
2. Limits of Confidentiality	19	(10)
PART II The Clinical Record	29	(40)
3. Contents of a Good Record	31	(25)
4. Families, Couples, and Group Psychotherapy	56	(7)
5. Supervision and Training	63	(6)
PART III: Documentation of Safety Issues	69	(42)
6. Danger to Self	71	(13)
7. Danger to Others	84	(18)
8. Abuse	102	(9)
PART IV Special Topics Relevant to Record Keeping	111	(34)
9. Treatment of Minors	113	(7)
10. Client Access to Records	120	(12)
11. Retention and Disposition of Records	132	(7)
12. Conclusions and Frequently Asked Questions	139	(6)
PART V Appendixes	145	(33)
Appendix A: Legal Citations	147	(3)
Appendix B: Case Record Example	150	(3)
Appendix C: Progress Notes Example	153	(5)
Appendix D: Treatment Plan	158	(1)
Appendix E: Billing for Services	159	(1)
Appendix F: Informed Consent	160	(1)
Appendix G: Consent Form for Audio/Video Recording	161	(1)
Appendix H: Fax Cover Letter Consent Form	162	(1)
Appendix I: California Limitation on Confidentiality: A Brochure for Clients	163	(2)
Appendix J: California's Consent and Disclosure Requirements for Minors	165	(1)
Appendix K: Answers to Vignettes Presented in Chapters	166	(4)
Appendix L: Ethical Codes Related to Record Keeping	170	(4)
Appendix M: Glossary of Legal Terms Pertaining to Psychotherapy	174	(4)
References	178	(4)
Index	182	(5)
About the Authors	187