The Psychotherapy Documentation Primer

by Donald E. Wiger

• ISBN13: 9780471289906
• ISBN10: 0471289906
• Edition: 1st
• Format: Paperback
• Copyright: 1999-01-01
• Publisher: Wiley

Summary

An ideal companion to Dr. Wiger2s well-received forms book, The Clinical Documentation Sourcebook, as well as the Psychotherapy Treatment Planners, this book explains the rationale behind, and the most efficient approach to, the paperwork required when providing mental health services in the era of managed care. This reference covers every stage of the treatment process, from the initial assessment to diagnosis, psychological reports, treatment plans, and progress notes. No clinician or trainee can afford to be without this accessible reference.

Table of Contents

Introduction	1	(4)
Overview of Current Documentation Procedures and Third-Party Requirements	5	(20)
The Biopsychosocial Assessment	25	(36)
The Mental Status Exam	61	(16)
Validating a Diagnosis	77	(20)
Treatment Planning	97	(32)
Progress Notes	129	(30)
Documenting the Need for Additional Services	159	(4)
Appendix A Documented Client Chart for Judy Doe	163	(12)
Appendix B Overview of Outcome Measures	175	(6)
Glossary	181	(10)
Bibliography and Suggested Readings	191	(4)
Index	195